Establish framework for future investigations

69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously subject to public inquiries or national investigations, such as Mid-Staffordshire NHS Foundation and University Hospitals Morecambe Bay NHS Foundation Trust. We intend to establish an expert advisory group who, over the coming months, will advise on the purpose and function of the new Independent Patient Safety Investigation Service. As part of this work, we will build on the useful insights that participants in this Investigation have shared. 70. We agree that independent non-statutory investigations provide a useful, more rapid and potentially more efficient alternative to statutory public inquiries as a last resort for investigating failings in care. This route has now been well tested and has the benefit of being able to engage with affected families, ensuring their key concerns are built into the Terms of Reference and can therefore be addressed by the investigation/ panel; and of not being a legal process which can inhibit people's willingness to engage openly and candidly. 71. We are considering whether we can use, or build on, the central Cabinet Office support provided to inquiries, including guidance for each stage of the inquiry, useful documents and access to a Whitehall officials' and former inquiry secretaries' network, and which is currently being updated and considered by a cross-Government group.

The Thirlwall Inquiry has noted action taken in response to this recommendation.

The Healthcare Safety Investigation Branch (HSIB) became an independent investigations body known as the Health Services Safety Investigations Body (HSSIB) in April 2023, through the Health and Care Act 2022. Its role is to investigate incidents occurring during the provision of health care services that have or may have implications for patient safety. The HSSIB will conduct investigations using a no-blame approach; this is supported by ‘safe space’ which encourages participants, including patients, families and staff, to share information in confidence. This aims to encourage the spread of a culture of learning within the NHS and independent sector. As set out in the Act, the HSSIB will also provide advice, guidance, and training to NHS bodies upon request.

HSSIB have established their own processes and principles around matters such as evidence handling and access to documentation. These processes are supported by provisions in the Health and Care Act, particularly on protected material, criteria, principles, and processes.

Please see response to recommendation 39 for details about the Maternity and Newborn Investigations Programme’s which investigates early neonatal deaths, intrapartum stillbirths and severe brain injury in babies born at term following labour in England, and maternal deaths in England.

NHS England has created a National Independent Patient Safety Investigation Framework (NIPSIF), which is an internally focussed approach to support the commissioning and management of independent investigations.

The Government is committed to ensuring that all women and babies received safe, personalised, equitable, and compassionate care. We are determined to learn lessons from inquiries and investigations.
The Healthcare Safety Investigation Branch became an independent investigations body known as the Health Services Safety Investigations Body (HSSIB) in April 2023, through the Health and Care Act 2022. Its role is to investigate incidents occurring during the provision of health care services that have, or may have, implications for patient safety. The HSSIB will conduct investigations using a no-blame approach, that is supported by a safe space which encourages participants, including patients, families, and staff, to share information in confidence. This aims to encourage the spread of a culture of learning within the National Health Service and independent sector.
As set out in the Health and Care Act 2022, the HSSIB will also provide advice, guidance, and training to NHS bodies upon request. The HSSIB has established their own processes and principles around matters such as evidence handling and access to documentation.
NHS England has created a National Independent Patient Safety Investigation Framework, which is an internally focussed approach to support the commissioning and management of independent investigations.

Department of Health response (July 2015):

A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. (p. 82)