In healthcare, as elsewhere, people make mistakes. The important thing is to learn why

Today there is widespread understanding that healthcare can learn from other safety-critical industries, like aviation. A new statutory body will help ensure that happens
Photo: Lydia/Flickr/CC BY 2.0 DEED

By Bernard Jenkin

19 Oct 2023

Have you ever had to complain about a botched hospital operation? Most MPs have had a victim of a medical failure or a bereaved relative in their advice surgery, saying, “We never wanted to complain, but nobody will tell us what actually went wrong or why, and we only want to make sure that something like this never happens again.” However, the culture in healthcare is still denial, not to admit mistakes and so be able to learn from them.

This month sees the launch of a new statutory body to investigate clinical incidents in healthcare, the Health Services Safety Investigation Body. A new act of parliament gives it statutory independence and special powers to investigate the causes of clinical failures without blame, and to make recommendations for healthcare safety improvements. It is modelled on the Air Accident Investigation Branch. In future, HSSIB will hear aggrieved patients and relatives, as well as clinicians who are concerned they have made an error. HSSIB has no power to judge or punish. Nor will it allow what people tell them to be used in court or in disciplinary proceedings against them. This is the first body of its kind in the healthcare sector anywhere in the world, but many countries are interested in copying our legislation.

Back in 2015, after the Francis inquiry into the Mid Staffordshire Hospital, health secretary, Jeremy Hunt, was candid with the Public Administration Select Committee. How many serious incidents per year? “About 30,000 every year, of which 10,000 are severe harm or death.” He also said there was massive under-reporting of avoidable deaths in the NHS. We asked “How well do you assess that the NHS and your department is doing this now?” and he responded, “I do not think we have cracked the problem at all.”

The following month, we reported to the House of Commons that the quality of most investigations into clinical incidents fell far short of what patients, their families and NHS staff are entitled to expect – “no systematic and independent process for investigating incidents and learning from the most serious clinical failures. No single person or organisation is responsible and accountable for the quality of clinical investigations or for ensuring that lessons learned drive improvement in safety across the NHS.”

The committee recommended that the government should bring forward proposals, and legislation, to establish a national independent patient safety investigation body. To his credit, before we finished drafting our report, Jeremy Hunt had announced to the House of Commons that the government was adopting this policy. There followed a year long consultation and many meetings of a consultative group of people involved with safety management and accident investigation, including with representatives of victims and the bereaved. 

"Today there is widespread understanding that healthcare can learn from other safety-critical industries, like aviation. People make mistakes. The interesting thing to learn is why, and how to avoid the same mistake in future"

The government then established a "shadow HSIB". The shadow HSIB has done its best to develop expertise and capacity, and has started to cut its teeth on investigations, but it could never function as the statutory HSSIB now will. It lacks independence, the necessary powers to require the NHS to give it access to information and people, and the crucial "safe space" for whistleblowers and others to speak freely.

Today there is widespread understanding that healthcare can learn from other safety-critical industries, like aviation. People make mistakes. The interesting thing to learn is why, and how to avoid the same mistake in future. Solutions can be very simple, like colour coding different intravenous drips, which has saved thousands of lives. 

HSSIB will operate outside the healthcare system. It has the power to investigate anything which it considers to be in the interests of patient safety, including any regulator like CQC or the National Midwifery Council. 

HSSIB’s most controversial special power is the "safe space" – the ability to receive information and personal accounts of incidents, which are protected from disclosure, even in court. The government has strived to promote a no-blame culture in the NHS.  It introduced the "freedom to speak up guardians", a "duty of candour" on NHS clinicians and staff. HSSIB will provide meaningful protection for people speaking up. There will be no more cases like Dr Bawa-Garba, a junior obstetrician who spoke freely, and then was wrongly convicted for manslaughter and struck off by the GMC for doing no more than telling the truth of her error. She was reinstated, but only after a battle. The causes of the infant death were systemic, not down to a single culpable personal failure. 

HSSIB is an entirely additional, permanent capability in healthcare devoted solely to promoting patient safety. It is not a regulator, or a prosecutor, or an advocate for anyone or anything other than for patient safety. The government provision for medical negligence cases is over £80bn. HSSIB will pay for itself again and again if it saves only a small fraction of that.

Bernard Jenkin MP (Harwich and North Essex, Conservative) was chair of the Commons Public Administration Select Committee (2010-1019)

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