The new independent body to look into clinical incidents in the NHS will improve the quality of investigations and provide families with ‘effective answers’, NHS England patient safety director Dr Mike Durkin has said.

  • Online consultation on new safety investigation body launched by Department of Health
  • Mike Durkin, who is leading establishment of IPSIS, criticises current standards of investigation
  • IPSIS due to launch in April 2016

Dr Durkin, who is leading work to establish the Independent Patient Safety Investigation Service, said he hoped the organisation would promote “continuous improvement” in services.

“At present we do not have a consistent system for investigations that can be used across all health providers,” he added.

Mike Durkin

Mike Durkin said ‘system error is at the heart of the majority of failings’

He said IPSIS would offer “acknowledgement and responsibility for learning from error and [seek] continuous improvement with trust, honesty and respect for each other at the core of our individual and organisational behaviour”.

Dr Durkin also said: “Patients and staff in every setting need to have confidence that the real causes of any failing in care we provide to patients will be identified. This is all the more important so that early actions can be put in place to remedy that failing.

“System error is at the heart of the majority of failings in care and not the actions of individuals. I believe IPSIS will set a path by leading innovation in the way we investigate incidents in healthcare so that patients and their families get effective answers to their questions in an improved and timely fashion.”

His comments come as the Department of Health launched an online consultation yesterday for patients’ and staff’s views on how they believe IPSIS should operate.

IPSIS is set to launch in April and was announced by health secretary Jeremy Hunt last month following recommendations by the Kirkup inquiry and MPs on the Commons public administration committee.

IPSIS is expected to be hosted within the new national regulator NHS Improvement, which is to be formed by merging Monitor and the NHS Trust Development Authority.

The changes, which include shifting patient safety responsibilities from NHS England to NHS Improvement, are likely to require legislation.

Dr Durkin is chairing an expert advisory group which has been asked to design the operating model for IPSIS. The group includes James Titcombe, who campaigned for an inquiry into the death of his son Joshua at the University Hospitals of Morecambe Bay Trust, and patient safety expert Carl Macrae. His article for HSJ sparked work on the idea of an independent investigation body which led to the public administration committee’s recommendations.

Dr Durkin revealed he has had a number of conversations with patients and families who had been “profoundly affected” by poor care.

He said harm to them was “often compounded by an inability for the organisation to recognise the impact of this harm and, at best, to poorly investigate the facts”.

“Quite rightly, I have already been challenged to make sure that we do this in a genuine way that will ensure patients and service users and their families can share their views and ideas with the advisory group. Equally, it is vital to hear from health and care professionals and understand the full implications for them as part of their professional roles and their day to day working lives,” he added.