Asking us to investigate a safety incident
- Cases are referred to us through the safety awareness form
- Each submission is logged and stored on our database – this is to help us see emerging patterns and builds a useful picture even if we don’t end up investigating that particular case. We aim to review the submissions on a regular basis.
- We review every form using our detailed criteria – we consider the impact, how widespread or common the safety issues are, and crucially, what the potential is to drive positive change and improve patient safety.
Making the decision to begin an investigation
- If we feel it meets our criteria, we’ll spend some time developing a case to investigate. This can involve research – for example reviewing literature or speaking to those outside HSIB with relevant subject expertise. We’ll then gather all the relevant documents or data
- We hold a weekly scrutiny panel to look at developed cases. They decide on the scope of the initial investigation and also identify the right team of investigators to work on it.
How we do the preliminary investigation
- We get in touch with those involved so that everyone knows that we are going to begin our investigation. As a patient, family member or carer, we’ll make sure you know what we’re looking at and how you might be involved
- We also always contact the CEO of the organisation involved through a formal letter
- The investigating team carry out a series of interviews – they’ll talk to many of those involved and work with patients and families and others to help them understand the incident better, and gain their perspective
- After this we hold an internal debriefing session that that all our investigators are up to speed on what we’ve found so far – this helps the wider process because even if not everyone is involved in that case, it helps our learning by showing where there could be links and connections with other areas
- We may publish an interim bulletin if we feel that there are clear recommendations or actions to share widely at this point. If you’ve been involved then we’ll keep you updated at key points, including sending a pre-publication for comments
How we do the full investigation
- It involves our whole HSIB investigative team, staff from the organisations and we also work with a range of independent Subject Matter Experts adding another level of specialist knowledge to the investigations
- Once we go to full investigation we might need to talk to family members and patients again – we aim to be flexible and can let you know as soon as possible
- Each investigation will differ and we will ensure that the methodology fits the case. However, there are broad areas that all will look at.
- Gathering of documents and data
- Determination of facts through a programme of interviews
- Analysing information that have access to about an incident
- Determining of causes or contributory factors
- Identification of safety issues and resulting safety actions
- Preparation of safety recommendations to improve patient safety
The process for a full investigation can vary so we’ll always publish key updates our website to keep everyone informed.
What happens when the investigation is complete?
- Once we have completed our investigation, we’ll contact patients, family members or carers to share our findings and get your feedback and input on the draft report
- It’s important to ensure that everyone is involved so we’ll also be sharing those safety recommendations and actions from the draft report with the organisations impacted by them.
- The final report you’ll receive a copy with all of the final safety recommendations and a full version is also published on the website.