A safety organisation drawing on lessons from the airline industry will have new legal powers to investigate serious patient safety incidents in the NHS in England, under plans laid before parliament.
The draft Health Service Safety Investigations Bill will establish and enshrine in law the powers of the Health Service Safety Investigations Body (HSSIB).
The bill forms a key part of the Health Secretary Jeremy Hunt’s plan to develop a more open, learning culture across the NHS.
The HSSIB will take forward the work of the current Healthcare Safety Investigation Branch (HSIB), which came into operation in April 2017 as a division of NHS Improvement.
Under the proposals, the HSSIB will be independent of the NHS and at arm’s length from government. It will have far-reaching access to investigate serious safety incidents or risks to patient safety.
After each investigation is completed, the HSSIB will publish detailed reports which will:
- make recommendations for system-wide learning across the NHS
- help develop national standards on investigations
- provide advice, guidance and training to improve investigative practice across the health service
Secretary of State for Health, Jeremy Hunt, said:
This draft bill represents a landmark moment for patient safety across our NHS, and is a historic opportunity to achieve widespread cultural change in learning from mistakes.
When significant errors occur, it is vital that health organisations react quickly and decisively to share lessons and make improvements. To achieve this we need to create an environment where patients, public and healthcare professionals all feel able to speak out about their concerns, without fear or favour.
A key feature of the HSSIB would be its new approach to investigations, which will protect the information it holds from disclosure.
The aim is to create a ‘safe space’ in which participants, including patients, families and staff, can share information in the knowledge that it will not be disclosed except in limited circumstances, or by order of the High Court.
It is hoped that the safe space model will encourage more participants in investigations to speak out about safety concerns to help identify and address risks across the NHS. This approach is already used in the safety-critical rail, aviation and marine industries – all of which have achieved dramatic improvements in industry safety.
The draft bill also proposes to give the HSSIB the power to establish an accreditation system across the NHS – supporting trusts who receive accreditation to conduct safe space investigations. This will further reduce unsafe and costly practice, improve investigations, and embed a culture of learning and improvement throughout the health service.
Keith Conradi, the chief investigator of the Healthcare Safety Investigation Branch and former head of the Air Accidents Investigation Branch, said:
We very much welcome the introduction of the draft Health Service Safety Investigations Bill.
It’s a key step towards HSIB’s independence and as the bill progresses, we look forward to hearing the variety of views and comments on the bill’s content.