There are several factors that trigger an investigation. It begins when we receive a notification through the safety awareness form. The specific incident must have:
· have happened after 1st April 2017
· taken place in England
· be within NHS funded care
Once we’ve established those details, our next step is assessing against our detailed criteria. We’ve made every effort to design this to cover a range of themes and circumstances.
There are three areas that inform our criteria:
The first area we consider is how these issues have impacted on both people and services. This is because we want to be looking at those issues that have the most profound impact. We always look at both the physical and emotional harm caused as a result, and we’ll usually explore this, gaining a staff perspective through the interview process.
In terms of services, we look how difficult the issue/s are making it to deliver safe and reliable care. We also take the wider view and look at public perception. We consider whether there is evidence that there has been a broader loss of confidence in that particular area of healthcare.
We always look at the wider system risk associated to the safety issues – effectively how common or widespread is it, and does it span different areas of healthcare and different locations. Some of the areas we consider include:
- do various care settings or organisations change the way they work to address a safety issues
- have the issues taken a while to be recognised and are they recognised at the right level
- has the issue existed over a long period time, and are concerns about that issue consistently raised
- will it get worse or spread into different areas of the system if not addressed.
We aim to put learning at the heart of everything we do. HSIB wants to drive positive change to improve patient safety and part of that is being able to clearly show that our investigations will produce new information about safety issues. We always look at whether we have a new perspective so that we can develop meaningful, influential and effective recommendations that benefit all of those working in or being for cared for by the health service.
evaluate at key points during investigations to ensure they are still meeting
our criteria and reflecting our main objectives and principles.