How we decide to investigate
What we consider before starting an investigation
There are many factors that inform our decision to start an investigation and it starts from the point that we receive the safety awareness form. Once we know that it happened after 1st April 2017 and England, we can look at the case against our detailed criteria. We’ve made every effort to design this to cover a varied range of theme and circumstances.
To give you some insight, here are the main areas we look at when we’re making our decision to investigate.
Outcome impact
Assessing the impact on people is a crucial part of our process. It helps us to identify the most serious issues as they’ve often had the most impact. We’ll always look at the physical and emotional harm that might have been suffered by anyone involved. As a patient, family member or carer, this is something we might explore with you during our preliminary investigations. Insight into how this has affected you is vital to building a full picture of the severity of the issues.
We also look at the impact on services, and whether the safety issues have, for example reduced the ability to deliver safe and reliable care. We also consider the public view and whether there has already been a broader loss of confidence in that area of healthcare
Systemic risk
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 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.
Learning potential
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.
We’ll always evaluate at key points during investigations to ensure they are still meeting our criteria and reflecting our main objectives and principles.