A new national safety investigator for healthcare: the road ahead

The most fundamental principle of patient safety is that we must learn from the past to improve the future. From April 2017, the English National Health Service becomes the first healthcare system in the world to have a specialist agency dedicated to investigating and learning across the entire healthcare system: the Healthcare Safety Investigation Branch. This represents a watershed moment. The use of system-wide, expert-led, learning-focused safety investigation is an essential feature of other safety-critical sectors such as aviation, but has long been missing in healthcare. In this journal in 2014, we set out the case for establishing a national patient safety investigator along with practical proposals for how it might function.¹ That paper triggered a Parliamentary select committee inquiry in 2015^2,3 and, after extensive consultation, legal directions and expert guidance for establishing the Healthcare Safety Investigation Branch were published in 2016.^4,5 Now the real work begins.

Healthcare Safety Investigation Branch will systematically and routinely investigate the most serious risks to patient safety across the healthcare system, publicly report on its findings and issue recommendations for improvement. These safety investigations are solely for the purpose of learning and will explicitly avoid allocating liability or blame. The independence of the Branch – still to be fully achieved – will allow it to investigate and make recommendations to any relevant party, including healthcare regulators, equipment manufacturers and education providers – organisations that cannot easily be influenced by other agencies. Building a trusted, respected and effective national safety investigator will take time and the challenges are considerable. Some challenges are technical, such as developing appropriate analytical and investigative methods. But in our view, the greatest challenges facing Healthcare Safety Investigation Branch are primarily social and cultural in nature. These are threefold. First, establishing the legitimacy, authority and independence of national investigative activities. Second, earning the trust and confidence of healthcare professionals, patients and the public. And third, creating systems that constructively support practical improvement across the healthcare system.

Independence: establishing legitimacy and an authoritative view

It is hard to overstate the critical importance of independence for a national safety investigator.⁶ Safety issues span the entire healthcare system, so Healthcare Safety Investigation Branch must be able to impartially investigate all organisations entirely free from conflict to build an authoritative system-wide view. Everyone must be confident that the sole purpose of investigation is learning and improvement, so the Branch must be entirely independent of any regulatory or oversight bodies. And a national investigator must remain entirely separate from the system it investigates, so the Branch must not become directly involved in implementing improvements. Healthcare Safety Investigation Branch has initially been formed as a functionally independent body under the auspices of a regulator, National Health Service Improvement.⁴ As an interim measure, this is understandable. But it is imperative that primary legislation is brought forward to establish Healthcare Safety Investigation Branch on an independent institutional footing. Without this, the Branch will have to work unnecessarily hard to combat the perception that it remains part of the regulatory establishment, meaning it may struggle to gain the professional trust, public confidence and authoritative view that its work depends upon.

Trust: accessing, protecting and disclosing safety information

The core purpose of a national safety investigator is to maximise system-wide learning from past events. This requires a deep understanding of the causes of safety issues, which in turn requires accessing detailed information about events. In practice, the most valuable information is often contained in personal memories of past events. The success of Healthcare Safety Investigation Branch will therefore depend on trust: people’s willingness to openly and fully engage with safety investigations. To encourage the open flow of safety information, healthcare professionals and organisations must be assured that any information generated solely for the purposes of safety investigation – such as witness statements or investigators' notes – will only be used for the purposes of learning and will not be routinely passed to regulators or courts. The Government has committed to establish ‘safe space’ protections to do just this.⁷ However, as in other safety-critical industries and in line with the principles of a just culture,⁸ any protection of safety information must be aligned with other responsibilities. Patients and families must be assured they will receive all relevant information in line with the duty of candour, and detailed investigation reports must be published publicly. Critically, it should be an offence to hide or tamper with evidence or otherwise interfere with an Healthcare Safety Investigation Branch investigation. While the Branch will rely primarily on trust and cooperation, it will need strong formal powers to access all relevant safety information from any party that attempts to conceal relevant information. Safety investigations should not generate any fear of being blamed, punished or victimised – but everyone should take seriously their responsibility to participate fully and openly in investigations intended to save lives.

Improvement: acting as a catalyst of learning and change

The ultimate objective of Healthcare Safety Investigation Branch is to bring about practical change and improvement across the healthcare system. As a small organisation with a budget of less that £4m a year, this will be challenging, but there are unique opportunities. An immediate challenge is determining where to focus investigative resources given the enormous quantity of safety incidents reported each year. Healthcare Safety Investigation Branch must be robust and systematic in prioritising its investigations, principally by evaluating the underlying systemic risk to patients and appraising the ‘safety value’ of investigation.⁹ The Branch has many opportunities to improve learning across the National Health Service. Two stand out. First, it is ideally situated to coordinate a national network of local investigators and safety specialists. This would allow the Branch to disseminate exemplary methods and expert guidance, draw on local expertise in the investigation of system-wide risks and establish systems for cross-boundary sharing of safety information, local lessons and peer support. Second, Healthcare Safety Investigation Branch is well placed to lead the development of innovative approaches to widely circulating safety lessons by using the power of patient stories to engage with professionals, patients and the public, particularly through media such as powerful and engaging films.^10,11 Ultimately, it will be essential that the work of Healthcare Safety Investigation Branch is rigorously evaluated, both to monitor learning from recommendations and to improve the effectiveness of the Branch itself.

A beacon for learning and improvement

Remarkable progress has been made in the short time since this journal published our proposal for a new national safety investigation body for healthcare.¹ Many challenges lie ahead, and the most complex concern the social issues of legitimacy, authority, trust, influence and learning. But, with careful thought and committed action, the Healthcare Safety Investigation Branch has the potential to lead the way in institutionalising one of the most fundamental tenets of patient safety improvement: a future in which the past is treated with the rigour, respect and sensitivity it deserves.

Declarations

Competing interests

CM declares consultancy in patient safety for National Health Service and other healthcare organisations. CM acted as an advisor to the Public Administration Select Committee inquiry into the investigation of clinical incidents in the National Health Service (2015), was a member of Healthcare Safety Investigation Branch Expert Advisory Group (2015–2016), and is advising Healthcare Safety Investigation Branch establishment team (2016–2017). CV declares consultancy in patient safety for National Health Service and other healthcare organisations and acted as an advisory to the Public Administration and Constitutional Affairs Committee in relation to the Government’s ‘safe space’ consultation (2016).

Funding

CV is supported by the Health Foundation.

Ethics approval

Not applicable.

Guarantor

CM

Contributorship

This article was prepared following discussions reflecting on the future of the Healthcare Safety Investigation Branch. CM had the idea for the paper, both authors contributed to the drafting.

Acknowledgements

None

Provenance

Not commissioned; editorial review.