Patient Safety initiatives announced by Jeremy Hunt

Published: 10 Mar 2016

On 9th March Secretary of State Jeremy Hunt announced three new initiatives regarding patient safety:

• The Healthcare Safety Investigation Branch (to be part of NHS Improvement later this year), to carry out around thirty ‘no-blame’ theme based investigations a year
• The introduction of Medical Examiners to investigate causes of unexpected hospital deaths and patient safety lessons from them
• A “Learning from Mistakes” league table of NHS trusts drawing on data from the staff survey and rates of reporting incidents

AvMA welcomes the commitment to introduce a system of Medical Examiners from 2018. This is something that was recommended from the Shipman Inquiry and again by the Mid Staffordshire Inquiry and the Morecambe Bay investigation. Pilots of medical examiners have shown promising results in identifying causes of avoidable deaths and identifying patient safety issues.

The ‘Learning from Mistakes League Table’ is more controversial. It may provide an extra incentive for poorly performing trusts to improve, but the effectiveness of league tables to drive improvement is questionable and some would say counter-productive.

The new Healthcare Safety Investigation Branch (HSIB) is to be welcomed, but many will be disappointed with its limited remit and capacity. It is only expected to conduct around thirty theme based investigations a year, so will do very little to address the widely acknowledged problem with the quality of local NHS investigations of serious incidents, of which there are about 10,000 a year.

Controversially, Mr Hunt announced that as well as being focussed on learning for patient safety rather than apportioning blame, his intention is that there would be legal protection of some information gleaned from investigations – even going as far as patients/families having to get a court order if they wanted to use such information in a legal case. Mr Hunt went on to say he was considering adopting a similar approach for all safety investigations – not just those carried out by HSIB.

AvMA fully supports staff taking part in investigations being supported and treated fairly and these investigations should not seek to apportion blame. There is also a sound case for some information being kept confidential However AvMA and others believe it is inappropriate to place any restriction on the ability of patients/their family’s ability to access and use information about their own treatment in the way they see fit.

Mr Hunt’s remarks came before he had had the opportunity to hear the advice from the expert group he established to advise him on how HSIB should work and which is expected to advise that not only should there be full disclosure of information about the patient’s treatment to the patient or their family, but that there should be no restriction on how they access or use that information.