Safety chief warns no reason not to act on first report

Speaking to HSJ, HSIB’s chief investigator Keith Conradi said the safety investigation body would now formally write to NHS Improvement, the Department of Health and Social Care and other national bodies with a deadline for them to respond of 90 days.

He said the national organisations should “look at the weight of evidence in our report” adding: “Our expectation is that these are things that are practical realities and we don’t see any reason why these bodies aren’t able to do the recommendations we are asking them to do.”

Mr Conradi told HSJ the “jury was still out” on how the organisations might respond but said he was confident there was no reason the changes it was suggesting could not happen.

His comments follow the publication of the first HSIB investigation report into a surgical never event involving the implantation of the wrong prosthesis in a 62-year-old man during total hip replacement surgery.

One of the recommendations is for the DHSC to bring in a new national barcode scanning system that would alert theatre staff that they had the wrong implants before the surgery took place.

Mr Conradi said he felt HSIB’s first report had done what local trust investigators were incapable of doing such as examining systemic national issues around data and scanning systems.

He said: “If we are really going to make changes that aren’t sticking plasters we need to make them at systemic levels and increase barriers against what we know will happen. Humans are fallible.”

On the introduction of a national scanning system he said: “I just don’t think, at the local level, trusts would have the capability to make that kind of recommendation.

“We are able to do something the system wasn’t able to do previously. We have got very strong recommendations, but it is the action that will speak the loudest. What happens as a result of this is now where we really have to focus.”

He said the “jury was still out” on how exactly the national bodies would respond adding: “None of the recommendations will come as a surprise to these organisations and there have been detailed discussions behind the scenes to discuss the direction we have been heading.

“What will be interesting is their response to the recommendations. I think we need to wait for that to see how well these hit home.”

He added: “We will formally write to each of these organisations and ask for them to respond to the recommendations with a deadline of 90 days. We will the publish their response.”

But he admitted at the moment HSIB had no ability to force the organisations to respond.

“That is absolutely correct. It is one of the things in the draft legislation, a requirement to respond, but at the moment we have no legal powers to mandate a response.”

The government has proposed making HSIB independent of the NHS and give it tough new powers to require cooperation and seizure powers as well as to demand a response from national organisations to its recommendations.