Hospital Dr News

New NHS patient safety investigation service will begin next year, minister says

A new independent body will investigate instances of clinical failure in the NHS, the government has announced.

The Independent Patient Safety Investigation Service will be run by new regulator NHS Improvement, which is being created out of the merger of Monitor and the NHS Trust Development Authority.

Health secretary Jeremy Hunt told Parliament that when things go wrong “they will no longer be swept under the carpet” and that the NHS must “listen, learn and improve”.

The patient safety investigation service will begin in April 2016, and is in response to Public Administration Select Committee recommendations.

Patient safety incidents are currently reported to the National Reporting and Learning System but the new system will select its investigations, and ensure lessons are learned.

The Department of Health said details would be worked out over the coming months.

Hunt said: “Modelled on the air accident investigation branch used by the airline industry, this will be central to the ‘no blame’ learning culture which has led to dramatic safety improvements in aviation – and it will do the same for healthcare.”

The Morecambe Bay Investigation was established by the Secretary of State for Health in September 2013. It was set up in response to a series of maternal and neonatal deaths at the trust between January 2004 and June 2013.

The investigator Dr Bill Kirkup concluded that its maternity services were beset by a culture of denial, collusion and incompetence.

Other actions to prevent such failings in future include a full-scale review into current maternity services and provision across the country, which started earlier this year, led by Baroness Cumberlege.

The government has also responded to Sir Robert Francis’ Freedom to Speak Up Review, in the wake of both the Mid Staffs and Morecambe Bay scandals.

Francis found that NHS staff are put off speaking up about patient safety issues because they fear being ignored or victimised, and that consequently organisations were struggling to learn from mistakes.

Hunt has committed to a number of measures from the Freedom to Speak Up review including:

– a national ‘whistleblowing’ lead to be located in the Care Quality Commission;

– ‘Freedom to Speak up Guardians’ to be appointed in all local NHS organisations;

– whistleblowing training for all healthcare workers.

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