• Healthcare Safety Investigation Branch will have a budget of £3.6m in first year
  • Expert advisory group calls for process to resolve historical complaints
  • Mike Durkin hails launch of HSIB as “a huge leap forward”

The new Healthcare Safety Investigation Branch will be operating from this autumn with a budget of £3.6m for around 30 investigations, HSJ has been told.

A new chief investigator, tasked with establishing the branch and how it will operate, is expected to be appointed in the next few months.

Mike Durkin image

Mike Durkin

Mike Durkin said the NHS needs to develop  good safety techniques ‘without blame or acrimony’

HSJ understands that although HSIB will be hosted by NHS Improvement the chief investigator will have full discretion on which cases will be investigated.

They will be expected to report to the health secretary and only the secretary of state can appoint or dismiss the chief investigator.

A report by an expert advisory group brought together by Jeremy Hunt to advise on the creation of HSIB recommended the government considers creating a new process to tackle historical cases as these will not be looked at by HSIB.

In its final report the group said: “Our examination of the evidence has reinforced that there is a range of shortcomings in the existing response to adverse events across the healthcare system.

“Investigations are often delayed, protracted and of variable or poor quality. They frequently fail to capture all relevant information, and may unhelpfully conflate efforts to learn and improve with attempts to determine liability and allocate blame.

“Within individual healthcare organisations, safety investigation is often poorly resourced, with limited access to the required expertise and skills and insufficient allocation of time. There is a fragmentation of responsibility for rigorous investigation, both within individual organisations and across the healthcare system.”

It said a separate process to resolve old cases would help deliver “truth, justice and reconciliation” for patients, families and staff.

National patient safety director Mike Durkin, who chaired the group, told HSJ the creation of HSIB was an opportunity to improve how the NHS learns from mistakes.

He said: “I have met many bereaved families and they have not been served well and there are staff members who have equally not been served well after making errors and mistakes. As a whole system we need to reflect on how we are supporting the development of good safety techniques without blame and acrimony.

“This is a big challenge but also a huge leap forward to have an independent body acting without fear or favour with the support of the whole system.”

He said the idea of a process, separate to the work of HSIB, to resolve historical cases was a good idea.

“How we do it needs to be in the best interest of the family and staff involved. What we have found is that there are many families who have still not been in a position to identify what went wrong or hear an appropriate response from the system within which they were left bereaved or harmed,” he said.

“I believe we should introduce a system whereby we can call on the best available support to come together to help these families. I don’t know what model that would look like and whether the government will be in a position to support it but I think that would be a good thing to do.”

The advisory group, made up of clinicians, patients and safety experts, also recommended the government considers making it an offence to hide or interfere with HSIB investigations and where the branch comes across wrongdoing, negligence or unlawful activity it must inform the relevant authorities.

Dr Durkin said HSIB would act immediately in these situations but they were likely to be rare.

He added: “The leadership qualities of the chief investigator are going to be paramount. The skill set and capability of the individual to identify not only the exemplar model of investigation and how to work with staff and families, but ensure lessons are identified, is absolutely key.

“The chief investigator needs to be able to stand up to scrutiny and demonstrate to the public that he or she will do the job that we as a country want. The field is very strong. We are going to be appointing the chief investigator, I hope, in the next few months.”

Dr Durkin said it was expected HSIB would consider around 30 investigations a year and it would not be limited to one theme. Health secretary Jeremy Hunt previously said he would ask the chief investigator to focus on maternity issues.

A Department of Health spokeswoman said it was considering the recommendations from the advisory group and would respond in due course.

NHS to face new patient safety investigations from autumn