On 1 April The National Health Service Trust Development Authority (Healthcare Safety Investigation Branch) Directions 2016 came into force.
These provide for the establishment of HSIB and set out some detail around how it will function.
HSIB will be investigating incidents or accidents which evidence risks affecting patient safety with a view to identification of improvements in the provision of services or the conduct of other functions carried out for the purposes of the health service.
In addition they will be encouraging the development of skills used to investigate local safety incidents, including suggesting standards which may be adopted in the conduct of such investigations.
So what kind of risks might fall within their remit? 3 categories are set out in the Directions but these are not exclusive:
- Risks resulting in repeated, preventable or common occurrences of safety risks/harm to patients
- Risks indicating a systemic problem with significant impact in more than one setting
- Those involving new or novel forms of harm or new or novel risks of harm
It is made clear that it is not the function of HSIB to identify civil or criminal liability or to apportion blame or support fault based legal or regulatory action.
One of the key parts of the Directions covers the concept of the “safe space principle”. This is based on the fact that HSIB believe that they will be best informed by comprehensive and candid contributions. They are of the view that these are more likely to be made where there is confidence that they will not be used for purposes of establishing blame or apportioning liability but the for the purposes of identifying improvements. Hence, the Directions provide that, unless there is an overriding public interest or legal compulsion, disclosures of material gathered by HSIB should be avoided so as to preserve the confidence of the investigatory and reporting process. The Chief Investigator has a key role here in terms of making decisions about disclosure and setting up protocols with other organisations.
In addition, HSIB must provide similar opportunities to patients, providers, commissioners and regulators for contributions.
More detail will be in the Investigation Principles to be published by the Chief Investigator. However those are not due to be published until 1 April 2017.
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