Healthcare safety watchdog, HSIB, has published its 2021/22 Annual Review. The review looks back on a year in which HSIB completed more than 700 reports and issued more than 1,800 safety recommendations to NHS and other organisations. This year’s review also marks the end of an era for HSIB as it moves its maternity programme to a new Special Authority, the Maternity and Newborn Safety Investigations Special Health Authority (MNSI), and prepares its non-maternity national investigation programme for safe space powers and statutory independent status as HSSIB. Meanwhile, recent concerns expressed by HSIB’s departing Chief Investigator, Keith Conradi, in an interview and an open letter to the Secretary of State for Health, suggest that despite HSIB’s efforts to encourage a healthcare safety culture, the NHS remains unwilling to evolve. What is HSIB? The Healthcare Safety Investigation Branch (HSIB) was set up in 2017 to carry out independent investigations into patient safety incidents and concerns in NHS care in England. HSIB’s investigations identify the factors which lead to patients being harmed and make safety recommendations to help the healthcare system learn and improve safety to reduce the risk of further harm. HSIB works closely with the patient, their family and the healthcare staff who were involved in the patient safety incident. Their reports do not make judgments about liability or blame. Since 2018, HSIB has also carried out maternity safety investigations. Currently, these include: maternal (mother) death during or up to six weeks after the end of pregnancy where the cause was related to the pregnancy or its management; the stillbirth of a baby who was healthy at the start of labour; the death of a baby within the first week of life; severe brain injury to a baby which is diagnosed within the first week of life; HSIB no longer routinely investigates babies with birth injury from hypoxic ischemic encephalopathy (HIE) where there was no apparent brain injury after the baby was treated with cooling, unless the family or NHS trust ask for an investigation. HSIB’s maternity safety incident reports replace the NHS trust’s own investigation. Their reports are not published but are shared with the family and the trust. In addition, HSIB publishes national learning reports to share the learning and make recommendations from patient safety themes identified during their investigations. Where HSIB makes safety recommendations to an NHS trust or other organisation, it is that organisation’s responsibility to act on them. HSIB’s investigations from April 2021 to March 2022 HSIB reports that during 2021/2022: HSIB completed 706 maternity investigation reports; HSIB made 1,740 maternity safety recommendations; 86% of families whose babies or mothers were harmed by eligible maternity safety incidents engaged with HSIB’s maternity investigations; HSIB published 22 national investigation reports, including a thematic review of 22 investigations since 2017; HSIB issued 73 national safety recommendations to 28 organisations. You can read our comments on some of HSIB’s published national learning reports here: Outpatient appointments intended but not booked after inpatient stays; Wrong site surgery; Suitability of equipment and technology used for continuous fetal heart rate monitoring; HSIB maternity programme year in review 2020/21; Timely detection and treatment of cauda equina syndrome; Missed detection of lung cancer on chest X-rays of patients being seen in primary care; Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit; Recognition of the acutely ill infant; Weight-based medication errors in children; Maternity pre-arrival instructions by 999 call handlers Unintentional paracetamol overdose in adult inpatients with low bodyweight; Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery; Clinical decision making: diagnosis and treatment of pulmonary embolism in emergency departments. Since HSIB’s formation in April 2017 it has completed 68 national investigation reports, including 200 safety recommendations, 155 safety observations and 50 safety actions to 53 organisations. It has also completed 2,247 maternity investigations since 2018. Its recommendations to NHS trusts, maternity services and providers of NHS care are designed to support the healthcare system to address system-wide safety issues, if necessary by changing existing procedures and practices, so that the learning from each investigation leads to improvements in health and maternity care. Throughout the review, HSIB points out that where safety recommendations are made, it is up to the healthcare provider, NHS trust or wider healthcare system to make that change. HSIB reviews the responses it receives from organisations which have been issued with recommendations but has no power to monitor the trust’s actions or force the organisation to take action and implement the change. HSIB’s efforts to motivate trusts to improve by sharing learning and others’ experience of good practise have included publishing responses on their website, and engagement through newsletters and meetings, but the frustration of being powerless to enforce necessary change on an NHS which is resistant to learning is clear from the report. Without the engagement and support of the NHS, or power to ensure that safety recommendations are followed, HSIB has little hope of making meaningful progress in improving patient safety and reducing harm. In a recent interview, HSIB’s departing Chief Investigator, Keith Conradi, expressed his frustrations at NHS England’s failure to prioritise patient safety. On his last day before he retired from HSIB, Mr Conradi restated his concerns in a published open letter to the Secretary of State for Health and Social Care. Urging the new health secretary to set an example by demonstrating patient safety leadership and encouraging health service leaders to do the same, he raised his concerns about the lack of interest shown by NHS England and Department of Health and Social Care (at all levels of both organisations) towards HSIB’s activities and their failure to prioritise or support a system which makes leaders accountable for patient safety. What happens next? Following a period of transition, in April 2023, HSIB will receive independent, statutory status as the new Health Services Safety Investigations Body (HSSIB) under the Health and Care Act 2022. HSSIB will carry out non-maternity patient safety investigations with increased powers, including safe space. From April 2023, HSIB’s maternity investigations will be carried out by a separate Special Health Authority, the Maternity and Newborn Safety Investigations Special Health Authority (MNSI). HSIB’s review suggests that the aim of MNSI will be to provide NHS trusts with the expertise, resources, and capacity to handle maternity safety incident investigations in the future. If you have been contacted by HSIB in relation to an injury caused by negligent medical care and would like to find out more about your entitlement to compensation, you can talk to one of our experienced solicitors, free and confidentially, by contacting us here.
