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:
· happened after 1st April 2017
· taken place in England
· within NHS funded care
Once we’ve established those details, our next step to assess against our detailed criteria – this covers a range of themes and circumstances.
We look at:
The area we look into is the impact on both people and services. This is to make sure that we’re focusing on those safety issues that are having or have had the most serious impact. We’ll look at the physical and emotional impact on patients, family members, carers or members of staff.
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 public perception. We consider whether there is evidence that there has been a broader loss of confidence in that 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 have to change the way they work in order 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 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 cared for by the health service.
We’ll always evaluate at key points during investigations to ensure it is meeting our criteria and reflecting our objectives and principles.