EAG publishes report on improving NHS safety investigations

The independent Expert Advisory Group (EAG) has published its report recommending how further improvement can be achieved by the Healthcare Safety Investigation Branch (HSIB) in the NHS’ investigation capability.

The report made 13 recommendations, including that: HSIB must be, and be perceived to be, independent and have this written in its legislation; the objective of safety investigations must be to understand the causes of harm in order to improve systems and prevent future harm, not to apportion blame or liability; patients, families and staff must be active participants in the process of investigation and must be engaged with and supported compassionately and respectfully; investigations must be led by experts; HSIB must publish reports that explain the causes of safety issues and incidents, and issue recommendations for improving patient safety across the system; HSIB must promote the creation of a just safety culture; HSIB must provide families and patients with all relevant information relating to their care, reflecting the responsibilities of healthcare providers; all information collected solely for the purposes of safety investigation must be protected, making sure safety information continues to be provided and has the confidence of healthcare professionals; safety information must be provided to investigators with the understanding that it will not be used inappropriately; and that hiding or interfering with evidence is unacceptable, and should be made an offence.

The report also recommended that the Department of Health (DoH) should provide more focus on creating a ‘just culture’ taskforce, improving the wider infrastructure of investigation and resolving outstanding and unresolved cases.

The DoH and HSIB have welcomed the report and will consider the recommendations made, and respond in due course.