Dr Mike Durkin, NHS England's Director of Patient Safety, writes about the work to establish the Healthcare Safety Investigation Branch.
We have come a long way – and there is still work to do before the EAG publishes its full set of recommendations – but I am confident and more convinced than ever that the hard work of the group and its stakeholders will make a real difference for patients, families and staff.
What we’ve been doing
Throughout the autumn we spent time engaging with patients, families and staff to get their opinions on how an independent patient safety investigation function should operate; and their views on what is required for the function to be completely committed to supporting the NHS to learn and improve.
We spoke to people at a number of events as well as gathering views via our online call for evidence and survey. In total we had more than 800 responses to our surveys and call for evidence, a fantastic number which has helped us enormously in shaping our recommendations.
This process allowed us the privilege of talking face-to-face with many people involved in investigations – patients, families and staff; including a roundtable event with clinicians where we listened to their views and how it feels to be involved in an investigation.
The richness of what we heard means it is not possible for me to do justice to everything in the space of this blog, but the main things we heard were:
- both patients and staff stressed that patients and their families should be at the heart of investigations, and need to feel safe to participate - they want to be treated with honesty and compassion and for processes to be transparent
- both staff and patients felt it was important that the investigation function is as independent as possible and able to make judgements without fear or favour, with both internal and external scrutiny required
- it should focus on learning from safety incidents in the NHS, as well as being able to investigate system-wide failures and develop and recommend solutions
- an essential measure of success is for any learning to be widely spread to prevent mistakes happening again, and for that learning to be embedded across the system
- access to information arising from the learning from investigations should be made much easier
- both patients and staff require more support during investigations and that they need to feel safe to participate
- it was emphasised that, at present, participation in an investigation can be a very lonely and stressful experience, and often people have significant concerns about the personal implications of providing evidence
All of this evidence is being fed into the EAG’s final report and I, and the group, are incredibly grateful to those who told us their stories.
One of the key things we heard from stakeholders, and the EAG themselves, was that the function’s original proposed title – ‘IPSIS’ (Independent Patient Safety Investigation Service) – could be improved. The name has therefore been changed and it will now be known as the Healthcare Safety Investigation Branch.
To head up the branch, the Department of Health is supporting the recruitment of a chief investigator, a role which is being recruited for now.
Through our engagement, and reflected in the advice of the EAG, we have heard that people want a chief investigator who is a credible, strong leader with an expertise in investigation; who is patient-focussed and visionary; and who is independent in thought, impartial and courageous.
Identifying a person with those attributes will be essential in the recruitment and decision making process, to ensure the right individual is appointed for the important job at hand.
The EAG will conclude its work this month. And I’d like to acknowledge here the tireless commitment of each member throughout this journey.
The chief investigator is likely to be in post in the summer. At that point, they will take on full responsibility for the work of the new branch, determining how it will operate and when it will begin its investigation work. Over the past 7 months we have been on an insightful journey and I am looking forward to the final steps of chairing the EAG and seeing the investigation branch being fully established as a vital service to support improvement across the NHS.