We share what we learn across the whole of the healthcare system for the benefit of everyone who is cared for by it and works in it.
In this way, we can raise standards, improve patient safety and support learning across the healthcare system in England.
We are here to:
- Conduct thorough, independent, impartial and timely investigations into clinical incidents.
- Engage patients and relatives, NHS staff and medical organisations throughout the investigation process.
- Help the patients and relatives understand ‘what happened?’ and what’s being done to prevent similar events in the future.
- Produce clearly written, thorough and concise reports with well-founded analysis and conclusions that explain the circumstances and causes of clinical incidents without attributing blame.
- Make safety recommendations to improve patient safety.
- Improve patient safety by sharing the lessons learned from investigations as widely as possible.
- Raise the standard of local investigations of healthcare safety incidents by establishing common standards and skills development.
- Encourage the spread of a just culture of learning with the NHS through promoting better standards for local investigations and improving their quality and effectiveness.
We use a range of approaches in our investigations focusing on identifying risk and the causes of incidents.
Safety issues for potential investigations can be shared by individuals, groups or organisations. The decision to start an investigation could relate to a single event, a series of events or an issue discovered through current, ongoing investigations.
All of our cases are logged and stored in a database and become part of a process of review to help identify themes and patterns of safety issues over time.
Learning not blaming
We act independently and we do not investigate on behalf of the families, staff, organisations or regulators.
We are able to make public safety recommendations to the healthcare sector.
All of our investigations result in a series of robust safety actions and safety recommendations for the organisations we’re investigating as well as other similar bodies.
We are investigators not regulators, so we don’t enforce regulations but we do monitor and publish the response to our safety recommendations. When it’s necessary we ask the Care Quality Commission and other regulatory bodies to take action
We are unable to investigate every incident that is shared with us, but every patient safety concern we receive is reviewed and stored in our database. This helps us to identify patterns of safety issues over time.
Please see the relevant section below with all the information about our approach, our criteria and process.