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Future of patient safety investigations

Between March and June 2018 NHS Improvement held a range of engagement activities asking people to share their views on how and when the healthcare system should investigate and respond to serious incidents.

The results

NHS Improvement has published engagement feedback on their website. You can access the link by clicking here.

They indicate that they received over 400 comprehensive responses to the engagement survey from a wide group of stakeholders. Workshops were undertaken and patients, families and staff contacted the Patient Safety Team to share insight and experience.

NHS Improvement has indicated that the most positive responses from contributors were received in relation to:

  • providing patients, families or carers with clear standardised information explaining how they can expect to be involved.
  • requiring organisations to have dedicated and trained support.
  • setting minimum training standards for boards and those signing off reports.
  • removing the 60 working day timeframe and allowing an investigation team to set the timeframe for each investigation and consultation with the patient or family or recommending a 60 working day timeframe but allowing providers some leeway on meeting it.
  • requiring each healthcare provider to have a trained head of investigation to support and oversee patient safety investigation management processes.

What happens next?

It remains to be seen whether the above points will be implemented. NHS Improvement has stated it will use the information gathered over the next 6 months to develop and test new ways of working for serious incident management and will provide further information in due course.

Aidan Fowler, the new National Patient Safety Director, recently gave an interview to the Health Service Journal (HSJ). You can access the article by clicking here.

Of note, he suggested to the HSJ that his vision for Patient Safety Policy in the NHS will likely include mandatory introduction of Patient Safety Directors for Trusts. He also envisaged that medical examiners would report to him.

Mr Fowler also indicated that it was likely that a new incident reporting system would be introduced to replace the national reporting and learning system. He confirms that the draft vision for patient safety strategy in the NHS will be published in March 2019 following a consultation.

What does this mean for me?

If you have any queries about the issues raised and what these results might mean for your Trust, or you would like to talk to an expert about risk management advice, please do not hesitate to get in touch with me, or a member of the team.

Please note that this briefing is designed to be informative, not advisory and represents our understanding of English law and practice as at the date indicated. We would always recommend that you should seek specific guidance on any particular legal issue.

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