Authored article

Help shape the Independent Patient Safety Investigation Service

Dr Mike Durkin, Director of Patient Safety, NHS England, discusses the plans for the Independent Patient Safety Investigation Service.

Last month, the Secretary of State for Health announced the government’s decision to establish a new Independent Patient Safety Investigation Service (IPSIS) to be launched in April 2016. I believe this is really good news for patients and their families and carers and also for NHS staff.

Patients and staff in every setting need to have confidence that the real causes of any failing in care we provide to patients will be identified. This is all the more important so that early actions can be put in place to remedy that failing. System error is at the heart of the majority of failings in care and not the actions of individuals. I believe that IPSIS will set a path by leading innovation in the way we investigate incidents in healthcare so that patients and their families get effective answers to their questions in an improved and timely fashion

The Morecambe Bay Investigation and the report of the Public Administration Select Committee brought welcome clarity and political will to a problem that tragically holds families and staff back when things go wrong and explanations are needed. At present we do not have a consistent system for investigations that can be used across all health providers.

To address this, we are in the process of setting up the new investigation service that will deliver investigation guidance to NHS and healthcare organisations

This investigation service will improve the safety and quality of care for people who use our health and care services. Our focus must be on ensuring there is an acknowledgement and responsibility for learning from error and seeking continuous improvement with trust, honesty and respect for each other at the core of our individual and organisational behaviour.

In its formal response to the reports mentioned earlier, the government proposed a set of operating principles for an Independent Patient Safety Investigation Service.

So how do we now design a capability to deliver on that?

I am chairing an expert advisory group that has personal and professional expertise in patient experience, safety, investigation and the delivery of health and social care. This group has been asked to advise on the design, scope, governance and operating model for IPSIS over the coming month. It will draw on the views and evidence presented to the group from many others with an interest in this area.

In recent weeks I have had a number of conversations with people who have been profoundly affected by the harm they or their family member have experienced, often compounded by an inability for the organisation to recognise the impact of this harm and, at best, to poorly investigate the facts. I thank them for their kindness in sharing their thoughts and ideas and I am looking forward to continuing to work with them. Quite rightly, I have already been challenged to make sure that we do this in a genuine way that will ensure patients and service users and their families can share their views and ideas with the advisory group. Equally, it is vital to hear from health and care professionals and understand the full implications for them as part of their professional roles and their day-to-day working lives.

We want to talk and listen to people from a range of backgrounds, organisations and perspectives, who can play a role in influencing the form and function of the new investigation service during its initial development.

We would like to hear your views on the scope and operation of the Service. We have developed a set of questions around the key considerations for you which are included in the online questionnaire.

I look forward to hearing from you and I hope we can work together and live up to the challenge set to deliver an expert investigation service that will hold the trust and respect of all those it will serve.

Published 25 August 2015