Healthcare Safety Investigation Branch (HSIB) Expert Advisory Group

The IPSIS Expert Advisory Group was set up to make recommendations on how the new Independent Patient Safety Investigation Service would work. Following feedback from the group and others, the function’s name was changed to the Healthcare Safety Investigation Branch (HSIB).

HSIB, which will operate from April 2016, will offer support and guidance to NHS organisations on investigations, and carry out certain investigations itself. This was announced by the Secretary of State in July 2015.

The Expert Advisory Group will make recommendations on the scope, governance and operating model. It will draw on the expertise of its members in patient safety, healthcare and investigation and evidence from a broad range of stakeholders, including service users and staff.

The Expert Advisory Group comprises a core group of individuals who met fortnightly from August to December 2015 and thereafter meet monthly. Other people may be co-opted or invited to contribute to ensure both the appropriate representation and that the relevant expertise is available.


  • Julian Brookes, Deputy Chief Operating Officer, PHE, and member of the Morecambe Bay Investigation team
  • Alison Cameron, Chair, Patient Safety Champion Network, Imperial College Health Partners
  • Fiona Carey, Co-chair of the East of England Citizen Senate
  • Deborah Coles, Co-Director INQUEST
  • Keith Conradi, Chief Inspector of the Air Accidents Investigations Branch (with David Miller, Deputy Chief Inspector of Air Accidents deputising)
  • Mike Durkin, National Director for Patient Safety and Chair
  • Dr Sunil Gupta, GP and Clinical Lead for Quality and on the Governing Body of Castle Point and Rochford CCG
  • Dr Bill Kirkup CBE, Chairman of the Morecambe Bay Investigation
  • Dr Carl Macrae, Senior Research Fellow, University of Oxford
  • Prof Martin Marshall CBE, Professor of Healthcare Improvement at UCL
  • Prof Jonathan Montgomery, Professor of Healthcare Law at UCL and member of the Morecambe Bay Investigation team
  • Scott Morrish
  • Will Powell, NHS advisor for
  • James Titcombe OBE, CQC National Advisor on Patient Safety, Culture & Quality
  • Dr Nick Toff, Director for Clinical Quality, Cambridge University Hospitals NHS Foundation Trust

The membership will be reviewed on an ongoing basis to ensure it maintains a broad representation of individuals and interests. Other people may be co-opted or invited to contribute to ensure both appropriate representation and that the relevant expertise and advice is available

What the EAG is considering

The Expert Group will be considering the following in terms of the operating principles and design of IPSIS.


  • objectivity: will take a non-punitive approach and its practices and recommendations will be intended for learning and improvement, not to find fault, attribute blame or hold people to account
  • transparency: act as an exemplary model of openness and transparency including genuine engagement with patients and their families throughout the investigation process, from start to completion
  • independent in action, thought and judgement: able to operate without fear or favour irrespective of its location The function will exercise its independence to get to the bottom of any patient safety incident that it examines; its findings will apply to any organisation or individual as it sees fit; and its processes, practices and outputs will be transparent and subject to external scrutiny
  • expertise: staffed by experts in patient safety, investigations, human factors and healthcare provision
  • learning for improvement: produce findings from investigations that will help deliver practical, proportionate solutions that address the root cause of the problem under investigation. It will also provide support to local investigators and commissioners in order to transfer skills and systematically increase the capability in a particular local NHS system


  • independence, governance and accountability
  • type of incident(s) that should be investigated
  • people, skills and operations
  • engagement and transparency

Meeting notes

Read meeting notes

Terms of reference

Seeking views on IPSIS

Views on the function were gathered from Autumn 2015 to January 2016 via a call for evidence and online survey. Evidence has now been analysed and used to inform the EAG’s conclusions.

Contact details