Our national investigations programme can look at safety events or risks which occurred within NHS-funded care in England after 1 April 2017.
Our decision to investigate is based on the impact on people and services, systemic risk and learning potential.
The first area we consider is how these issues have impacted on both people and services. This is because we want to look into the 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 at 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 with the safety issues – how common or widespread a patient safety concern is and whether it spans different areas of healthcare and locations.
Some of the areas we consider include:
- do various care settings or organisations change the way they work to address a safety issue?
- 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 of 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. We want 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 safety recommendations that benefit all of those working in or being for cared for by the health service.
We’ll always evaluate at key points during investigations to ensure they are still meeting our criteria and reflecting our main objectives and principles.