The Department of Health has stated that the HSIB will conduct 30 investigations a year and have an annual budget of £3.6 million. The branch will comprise a chief investigator and an investigation team, with access to specialist expertise as considered necessary by the chief inspector.
In the 12 months leading up to October 2015, nearly 1.8 million adverse events in the NHS were reported to the National reporting and Learning System (NRLS). Of these, over 10,600 were reported as causing severe harm or death. Analysis by Hogan, Darzi and Black has found that 3.6% of hospital deaths in England have a 50% or more chance of being avoidable – 150 avoidable deaths a week.
Although not all adverse events are avoidable, and not all errors have adverse consequences, these numbers confirm that undertaking investigations will play just one part of the role the branch will have in improving safety through learning. A much greater impact will come from “encouraging the development of skills used to investigate local safety incidents in the health service and to learn from them, including suggesting standards which may be adopted in the conduct of such investigations” as listed in section 5 of the National Health Service Trust Development Authority (Healthcare Safety Investigation Branch) directions 2016.
Whilst there have been great advances in the understanding of the part that human factors play in error and adverse events, led by other high-risk industries such as aviation and nuclear fuel, there is still a strong blame reaction in many parts of the health service when things go wrong. Taking a systematic approach to investigating any incident is the only approach which gets to the bottom of what happened, why it happened, and what can be done to prevent a similar incident happening again.
In the past 12 months, over 1000 people have attended Verita’s accredited one-day training course on conducting systematic investigations. Feedback has been overwhelmingly positive with delegates feeling more confident to undertake investigations after the training. The task of building a well-trained, experienced and skilled resource to investigate safety incidents at local level and to embed a culture of learning is a huge challenge. If achieved, it has the potential to create a sustained change in our response to adverse events and create a culture of safety, learning and improvement. We hope that we can bring our experience to support this important and substantial task.
A personal case study
In twenty years of representing thousands of doctors whose professional conduct and competence was in question, I never came across a case where the issues were isolated to the individual concerned. There was invariably an organisational component, some aspect of the working environment, which contributed to varying degree, to the circumstances under investigation. A trainee surgeon is suspended from practice and investigated following failed sterilisation procedures on two women by keyhole surgery. The starting assumption being that this was ‘operator error’. But taking a big picture approach revealed that the surgical technique was beyond criticism. The problem was that the critical surgical instrument was faulty and the maintenance policy had not been followed. New and temporary staff were unaware of it. These underlying system issues significantly contributed to mistakes taking place at the sharp end.