Patient Safety Watch: HSSIB saved – now let it get on with the job

Good afternoon, and welcome to the latest edition of the Patient Safety Watch newsletter. There’s some good news to start with this fortnight, so let’s get stuck in.

Government drops plan to abolish HSSIB

The government has dropped its plan to abolish the Health Services Safety Investigations Body and transfer its functions to the Care Quality Commission. The decision to drop the proposal, which formed part of the Health Bill, follows a sustained campaign by Sir Bernard Jenkin MP, alongside interventions by the All-Party Parliamentary Group on Patient Safety and others.

At the Bill’s second reading in the Lords on 13 October, peers from across the House questioned the move, and health minister Baroness Merron promised to listen to their concerns. The government has now tabled amendments to remove the provisions abolishing HSSIB.

The amendments appear in the Lords’ running list of amendments, for consideration during committee stage, which begins on 28 October.

My view? This newsletter has argued repeatedly that transferring HSSIB’s functions to the CQC would be a serious mistake, so this decision is hugely welcome. Thanks are owed to Sir Bernard, alongside others including Carl Macrae, the Clinical Human Factors Group and the APPG for Patient Safety, who have made the case so clearly.

Safety investigation and regulation serve fundamentally different purposes. Losing an independent HSSIB would have been a tragic step backwards.

Credit is also due to ministers for listening. Now it’s time for HSSIB to crack on with its world-leading work – and for the system to make sure its recommendations are owned and acted on.

Amos review heard evidence of ‘normal birth ideology’, says Kirkup

On maternity safety, Bill Kirkup, who chaired the Morecambe Bay and East Kent investigations, has written to the Commons health and social care committee to put on record that the national maternity and neonatal investigation led by Baroness Amos heard and saw evidence “strongly suggestive of ‘normal birth ideology’”.

As HSJ reported, he claimed seven investigation members, including himself, acknowledged that evidence, which related to at least two of the sites reviewed.

Despite this, the final Amos report concluded that “normal birth ideology” was not found in the maternity services it visited. Dr Kirkup resigned before publication because he could not support the finding on this issue.

This matters because the Amos report contains important recommendations, but some voices have used its conclusion on this issue as proof that “normal birth ideology” is not a current problem in NHS maternity services.

If the evidence showed this to be true, it would be hugely welcome by everyone. But Dr Kirkup’s account raises serious questions about whether the Amos review had a sufficiently robust methodology to reach that conclusion, and whether relevant evidence was consistently considered. A finding based on those weaknesses risks providing dangerous false assurance.

During the Baby Loss Awareness Week debate last week, health secretary Yvette Cooper said: “There is no place for any ideology in childbirth.” The forthcoming maternity and neonatal action plan must now turn those words into practice.

And those words matter, because the language persists. A recent Stockport Foundation Trust advert for a delivery suite coordinator asks the post holder to “encourage and support midwives to engage philosophy and principles of the midwifery agenda thus promoting normal birth”.

Meanwhile, The Japan Times reports that Japan’s two national obstetric bodies have dropped the term “abnormal delivery” for births involving medical intervention, recognising its potential to distress parents.

Language shapes expectations. The priority should always be safe, personalised care, and informed choice.

Inquest examines avoidable delay in escalation before baby’s death

An inquest into the death of Effie Forrester, who died just 23 hours after being born at Morecambe Bay’s South Lakes Birth Centre in September 2025, will examine an avoidable 25-minute delay in delivery by caesarean section.

An independent expert identified failures to escalate concerns about abnormal fetal heart rate monitoring. University Hospitals of Morecambe Bay FT has indicated that it accepts an avoidable delay occurred, although whether earlier delivery would have changed the outcome remains uncertain.

The inquest will also examine concerns about Effie’s resuscitation, including difficulties managing her airway.

Midwives struck off after baby’s death

Two midwives at King’s Mill Hospital, managed by Sherwood Forest Hospitals FT, have been struck off after leaving a bleeding pregnant woman waiting 37 minutes to be assessed. As reported by The Independent, an inquest in 2024 found neglect contributed to the baby’s death, and the coroner ruled that had the mother been seen on arrival, the baby “would on balance have survived”.

Families’ concerns about maternity investigations remain unpublished

As HSJ reported, concerns have been raised about the continued non-publication of an independent evaluation of families’ experiences of reviews and investigations following baby deaths.

The Maternity Investigations and Review Tools process evaluation, by University of Manchester researchers, examined family experience of Perinatal Mortality Review Tool reviews and Maternity and Newborn Safety Investigations. HSJ reports that the Department of Health and Social Care received the completed study around 18 months ago. It has even been referenced in October’s PMRT report, yet its findings remain unpublished. The university expects publication in spring 2027, following peer review.

A detailed report has been shared with, and used by, government, yet the bereaved parents who took part – and the public – remain in the dark about what it found and recommended. That surely cannot be right?

In other patient safety news…

Trust prosecuted over children’s sepsis deaths

The CQC is prosecuting Mid and South Essex FT over the deaths of two young children with sepsis at Broomfield Hospital. As the BBC reported, two charges relate to Zadie Ajetunmobi, three, who died in November 2022, and a third to Selina Samarina, two, who died in April 2023. The trust is due to appear in court in December.

Separately, HSJ reports that an independent review into 10 child deaths has identified serious failings in governance and sepsis care at the trust.

Suicide claims highlight failures to involve families

NHS Resolution has published a thematic review analysing 960 suicide-related claims against mental health trusts, alongside a detailed qualitative review of a representative sample.

Family engagement was absent in 76 per cent of the cases reviewed. The report highlights recurring problems with communication, risk assessment and coordination of care – and the importance of listening to families as partners in keeping patients safe.

Trusts and providers urged to check e-RS referrals are not being lost

Trusts and other providers using the NHS electronic referral service (e-RS) are being encouraged to check what processes are in place to identify referrals that drop off worklists, according to a new report from HSSIB.

The e-RS automatically removes a referral from a provider’s worklist if no action has been taken after 180 days. It does not alert staff, so referrals can disappear before patients are booked in, resulting in missed or delayed care.

HSSIB found multiple incidents since 2018 where this had happened, including one where around 1,000 patients had to be added back onto a worklist. NHS England has said the 180-day limit cannot be extended because e-RS was not designed to cope with current referral volumes.

Nick Woodier, HSSIB senior safety investigator, said: “This risk cannot currently be removed from the system, but it can be mitigated. Where there is any doubt, we encourage providers to act now.”

The report encouraged providers to assess the risk of referrals disappearing, review weekly worklist drop-off reports, and ensure teams work together to identify lost referrals.

HSSIB understands that NHSE is updating its national clinical risk documentation for e-RS.

Action against Medical Accidents calls for complaints reform

Action against Medical Accidents (AvMA) has published a new policy paper, Making the NHS Complaints Process Fit for Purpose, drawing on more than 40 years of supporting people affected by avoidable harm.

The paper argues that complaints are a critical part of the patient safety system. It calls for independent investigation where complaints involve avoidable death, serious harm or significant conflicts of interest. In the most serious cases, it argues, the NHS should not investigate itself.

It also calls for independent advocacy and support, alongside the restorative principles of the Harmed Patient Pathway, so that the response to harm does not cause further harm.

An important and timely contribution – well worth a read.

Sharing some good stuff…

HSSIB contributes to award-winning project

Fittingly, Making Remote General Practice Safer, a collaboration involving HSSIB, Bangor University, the University of Oxford and NHS Resolution, has won the 2026 John Horder Practitioner Team Award.

The project developed training resources for whole general practice teams, bringing together clinical, research and safety investigation expertise.

Why do safety recommendations fall short?

A study highlighted by the National Institute for Health and Care Research Patient Safety Research Collaboration: Greater Manchester explores why national safety recommendations do not always deliver the improvements intended.

Published in the International Journal for Quality in Health Care, it examines the processes through which recommendations are developed and the challenges of turning them into action – timely reading as HSSIB looks ahead.

That’s all for this edition. Thanks for reading. Please look out for the next Patient Safety Watch newsletter from Jeremy in a fortnight.

James