Establish framework for future investigations
Morecambe Bay Investigation · Report of the Morecambe Bay Investigation · Issued 3 March 2015 · Addressed to: Department of Health and Social Care
Source — verbatim from the inquiry
●Inquiry recommendation
This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were overcome, but the need to do this from scratch each time an investigation of this format is set up is unnecessarily time-consuming. We believe that this is an effective investigation format that is capable of getting to the bottom of significant service and organisational problems without the need for a much more expensive, time-consuming and disruptive public inquiry. This being so, we believe that there is considerable merit in establishing a proper framework, if necessary statutory, on which future investigations could be promptly established. This would include setting out the arrangements necessary to maintain independence and work effectively and efficiently, as well as clarifying responsibilities of current and former health service staff to cooperate. Action: the Department of Health.
Morecambe Bay Investigation, Report of the Morecambe Bay Investigation · 3 Mar 2015 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- HSIB was established in April 2017 as a non-statutory body conducting independent healthcare safety investigations.
- Part 4 of the Health and Care Act 2022 established HSSIB as a statutory independent body with formal powers including entry, inspection, and seizure; the power to require information disclosure; and protections making investigation material generally inadmissible in legal proceedings (Health and Care Act 2022, c.31, sections 109-130).
- HSSIB became operational on 1 October 2023 as "a fully independent arm's length body of the Department of Health and Social Care" (HSSIB).
Response — verbatim from government
●Department of Health and Social Care
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.
Complaints: 31
Department of Health and Social Care · 16 Jul 2015 Written response →
Evidence trail — what's actually happened since
- 31 Dec 2015 Healthcare Safety Investigation Branch (now HSSIB) established with statutory framework for independent investigations under Health and Care Act 2022. Source →
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
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Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
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