Ideas for a crucial component of an exemplary service

Guest blog by:  Richard von Abendorff, patient safety campaigner and a Patient Public Voice in NHS Improvement


I call on HSIB to consult openly about its protocols and I invite any patients, families and whistleblowers who have not been approached by HSIB – to contribute ideas with comments to this site. I set out below some general good practice principles for engagement, which I think HSIB should consider.

A: Introduction – despite very challenging circumstances, unity in ultimate goals

The Healthcare Safety Investigation Branch (HSIB) was established in response to a Parliamentary Select Committee report, which criticised the quality and independence of investigations into NHS safety failures. Ref1

There are many challenges it faces and the report of the Expert Advisory Group Ref2 which helped develop the model identified’ tensions’ around issues like safe spaces, and the body’s’ structural independence. I summarise some of the developments as they are known now (15/2/17) in the final section of this report (C) to provide a valuable context (explaining the information I have gleaned, my perspective and also of interest to those new to the whole process which I have been following for over 5 years as I await a proper investigation – in vain it now appears).

But the main focus of this paper is in section B on key constructive steps forward which I believe the HSIB has to take. If taken these will in turn aid resolution of the current continuing scepticism and concerns of many patients and health care staff. I intend this to be just the start of a wider public discussion which the HSIB then engages with.

There without doubt are very different background interests and ongoing pressures on the key parties involved whether they are patients and their families, front-line staff who provide the service, whistle-blowers identifying the service failing or harm event, managers and providers, regulators and external bodies like PHSO (the final point of call for patients who want a proper investigation and remedy and believe they have not received it), and indeed (speaking as a campaigner)many campaigning organisations and individual campaigners

However, some shared core goals are acknowledged by all involved

A) The vital need to improve learning from incidents of harm in the health service and to promote changes to ensure no other patients are harmed in the same way.

B) That this process is made more expert and independent

C) That the process is made more efficient and does not further traumatise parties, as it does for many patients’ families and whistle-blowers

D) That the wishes and insights of patients and their families are listened to and acted upon to ensure all of the above – this external, consumer user voice with no other hats on is essential

Moreover, the HSIB has not only to implement this radical new model of working but do it transparently, because

• It is good practice

• As the expert group report argued it will help establish the essential trust needed, particularly for patients and their advocates

• And if HSIB is to be an exemplary model, this is essential

This challenge for HSIB is increased in the context of growing financial constraints, public scrutiny, while establishing a new service with a relatively small budget, taking on a minute fraction of cases being processed by the system, where many families are awaiting some kind of immediate justice, as well as whistleblowers still awaiting some kind of action which protects them Ref20

Issues of transparency and inclusivity are particularly important given recent concerns about a parallel project to HSIB derived from the Expert Advisory Group– the Just Culture taskforce. Ref3

Too many reviews to date have been, as far as I can see set up and tightly controlled by the very bodies who are having to reform their processes due to decades of failings not going properly addressed. I hope and expect HSIB to be different.

B: How HSIB could model meaningful patient involvement – feedback welcomed

1) In the light of this reality, I propose that HSIB should explicitly have an exemplar protocol on how it will involve patients, families and their advocates.

This will play a crucial role in addressing many of these real live concerns of patients and their advocates, and in providing the optimum conditions for success will contribute towards the development of this vitally important development particularly at these times of financial pressure on the NHS and public scrutiny

In my role as a Public and Patient Voice with NHS Improvement, I have witnessed attempts to co-produce its engagement approach with PPV’s, and I believe If HSIB is to be an exemplar and to lead on culture change nationally, it should operate in a fully open manner, and it should be strongly patient focussed. Fully empowered co-production is essential, but what will that mean? Some points are made here:

2) Best practice would mean it operates in a fully open manner. Moreover it would also require a culture in which HSIB opens itself to candid and constructive challenge from patients and their advocates, and embeds such challenge in all its operations.

3) Best practice is for patients to fully and meaningfully involved at all levels of operations. As a group, led by the safety and health quality expert Don Berwick, noted in the government report ‘A promise to learn, a commitment to act’:

“Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.” Ref 4

In particular, the perspectives of those harmed or who have experienced cover ups is essential in mapping out where improvement is needed in the NHS. The HSIB EAG noted:

“Those involved or harmed in safety incidents – whether patients, relatives or staff – must have the opportunity to be fully involved in investigations into what has happened”

The secondary harm caused through poor and ineffective investigations cover up and on occasion treatment of complainants as vexatious and other forms of victimisation particularly of whistle-blowers must be addressed. Victims of these kinds of events will have insights to ensure policies, procedures and safeguards are designed to prevent of these unacceptable practices

4) Principles of equality and diversity also need to be embedded involving a range of patients, family and advocates reflecting the wider demographic of the population who use the NHS. Ref5

5) True involvement requires true power sharing, through access to information and a genuine stake in making decisions at an early enough stage to influence HSIB’s processes. It should be a two way process, and not just a question of patients and their advocates passively providing feedback to HSIB. Rather, they should have a real opportunity to influence what HSIB does with the information at systemic level. Ref6 and 7

As a recent trial of structured patient involvement demonstrated, a critical part of such initiatives is to ensure effective listening and responsiveness by organisations. Ref8 Without this, there is no improvement in safety.

6) The levels at which stakeholders could play a vital contribution are:

• Designing and deciding HSIB’s scope, processes and protocols

• A voice in deciding the highest priority areas for investigation

• A voice in how individual investigations are conducted

• A voice in the scrutiny and evaluation of HSIB’s work

• Following up on implementation of recommendations, at times with other health service bodies to which HSIB may refer

7) Best practice would also include levelling the playing field through the provision of appropriate information, support and advocacy for patients and families. This should apply during individual investigations and when patients and families take part in HSIB’s overarching governance processes.

8) With regards to HSIB’s scope, a crucial question is how HSIB will relate to the PHSO. This has not been addressed at all by PACAC in an important recent report Ref9, but cannot be avoided: how will HSIB scrutinise PHSO’s much criticised and variable investigation processes? PHSO will remain the final recourse for the vast majority people who wish to complain about poor NHS investigations, many of which are about patient harm events, and it is important that PHSO’s investigations are of a consistent and acceptable standard. HSIB must engage with this core part of the present failing system which gives feedback to so many Trusts about their investigations. Understanding the root system failings of too many PHSO investigations is required to enable adequate evidence based reforms, especially at this time when new legislation is being considered and a new Ombudsman, Rob Behrens starts his post Rref 11

But what then of PHSO’s role in processing complaints about public sector bodies – will complaints about HSIB be investigated by PHSO? Or should there be separate provision for HSIB, to avoid such circularity?

9) This will present challenges for the recruitment and support for patients, families and their advocates. HSIB will have to model this and in so doing recommend how local services and other bodies include and develop this key resource for all services. Tokenism will not do. If patient advocate and whistleblowers voices are wanted , and as I say i believe they are required, they should be publically sought, with clear role descriptions and selection processes with significant input from independent respected individuals and organisations to ensure they are not hand-picked by the ‘great and good’. This is part of the culture that has to change.

In conclusion as Ocloo and Matthews argue we have to move from tokenism to empowerment. For too many exclusion and victimisation has been their only experience of the investigation system. Ref5. HSIB has to openly engage with this set of challenges.

Recognising that I am but one patient advocate voice I urge others to respond with suggestions and comments to this draft manifesto for patient engagement with HSIB. If this is not done now then when? Please send comments to me via this blog. Any help you can lend would be much appreciated and I hope as many comments as possible will be made public as well as the response by HSIB. These processes must be transparent

C:  Background to HSIB as at February 2017: key issues, controversies and tensions-challenges requiring an empowered patient voice

The Healthcare Safety Investigation Branch (HSIB) was established in response to a Parliamentary Select Committee report, which criticised the quality and independence of investigations into NHS safety failures. Ref1 In March 2015, the Public Administration Select Committee (now the Public Administration and Constitutional Affairs Committee) recommended the creation of an independent investigation body. Ref12

The government responded by creating HSIB, but controversially located it within NHS Improvement, and did not fully enact PASC’s recommendations for legislation Ref13,14 Bernard Jenkin the Chair of PASC raised a concern about the lack of immunity for staff giving evidence to HSIB Ref15 The committee also strongly condemned the lack of independence for HSIB.Ref16 Ambiguity about what ‘immunity’ and ‘safe space’ comprise within HSIB investigations has been the subject of much controversy and is not yet fully resolved. Ref17

A Chief Investigator, Keith Conradi – Chief Inspector of the Air Accident Investigations Branch 2010 to 2016 – was appointed and took up post in September 2016. Ref18

Keith is reported to be seeking statutory independence and additional powers for HSIB.Ref19

Little else has been made public to date. HSIB has a budget of £3.6m. It is to undertake 30 investigations a year, and investigations may feature more multiple cases and locations. It is expected to be an exemplar and to support improvement in investigation quality throughout the rest of the NHS. Keith has now said that HSIB is intended to be operational by April 2017. Ref19

According to the Health Service Journal, Keith has appointed a physician to head HSIB’s intelligence unit, which will identify potential matters for investigation. Keith has also indicated that there will be “no immunity”, and that HSIB will report “wrong doing, an unlawful act or huge significant harm” to the “appropriate authority”. Ref19 However, Keith has not fully assuaged concerns about the potential misuse of ‘safe space’ to conceal the full facts about failures.

He has indicated that information provided to patients and families will be filtered and that not all original documents may be disclosed. Ref19 He has however, rejected the government’s proposal that safe space should be extended to all NHS investigations, the great majority of which will not take place under HSIB’s auspices.

Keith commented to the Health Service Journal “We are not doing the investigations purely to get information for the families”. A question arises of how sensitive HSIB will be to the perspective of patients and families, and their advocates.

HSIB has not answered questions to date how explicitly it would involve patients, families and whistleblowers in drafting its protocols. Issues of transparency and inclusivity are important. This is especially so given recent concerns about a parallel project derived from the Expert Advisory Group (EAG) which helped to develop HSIB 10 – the Just Culture taskforce. Ref3

This is why this paper has been written. To start a transparent discussion how patients, families and whistleblowers will be engaged with. I eagerly await public feedback to this paper and transparent engagement with HSIB


A few patient safety campaigners I will not name now have inspired me through action and words to spell out some of the core ideas in this paper and one in particular has been essential to help articulate them. Many many thanks.


1 Investigating clinical incidents in the NHS. Report by Public Administration Select Committee 27 March 2015

2 Report of the Expert Advisory Group, Healthcare Safety Investigation Branch May 2016

3 Call for Just Culture task force core members to stand down, Minh Alexander 25 January 2017

4 A promise to learn, a commitment to act. Government response to the Mid Staffs Public Inquiry. Don Berwick et al, August 2013

5 From tokenism to empowerment: progressing patient and public involvement in healthcare improvement Josephine Ocloo & Rachel Matthews

6 Patient Engagement in Patient Safety. A Framework for the NHS. Sign up to Safety. May 2016

7 Safety is personal. Partnering with patients and families for the safest care, Lucian Leape Institute 2014

8 Can patient involvement improve patient safety? A cluster randomised control trial of the Patient Reporting and Action for a Safe Environment (PRASE) intervention. BMJ Quality and Safety, Rebecca Lawton et al, 3 February 2017

Evaluating the PRASE patient safety intervention – a multi-centre, cluster trial with a qualitative process evaluation: a study protocol for a randomised controlled trial. Laura Sheard et al. Trials 2014, 15:420

9 Will the NHS never learn?


11 Rob Behrens approved as Parliamentary and Health Service Ombudsman

New Draft PSO Bill

Fatal extraction: New Health Service Watchdog has all teeth removed.

12 Investigating clinical incidents in the NHS. Report by Public Administration Select Committee 27 March 2015

“Our main recommendation is that the Secretary of State for Health should bring forward proposals, and eventually legislation, to establish a national independent patient safety investigation body. The cost of this body will be relatively small, compared to the costs and liabilities arising from clinical incidents at present. This will involve the development of a body of professionally qualified administrative and investigative staff, who, over time will be able to provide a substantial infrastructure in support of all investigation of clinical incidents.”

“There will have to be clear criteria for deciding which incidents it should investigate, to avoid being overwhelmed by the large number that require routine investigation across the NHS”

13 Learning not blaming. Government response to PASC. July 2015

14 Government response to PACAC’s follow up inquiry on the quality of NHS incident investigations. 18 October 2016

15 Hansard debate on NHS reform 16 July 2015

“May I pick up on the Secretary of State’s reluctance to provide special legislation for the immunity of those giving evidence to the new patient investigation body? Will he keep an open mind on the subject? If he wants that body to be truly independent and to have a special status, he should remember that the marine accident investigation branch and the air accidents investigation branch have specific legislation to provide for such immunity. Public interest disclosure protection must not be challenged by freedom of information requests, given that freedom of information has been extended into areas where we never imagined it would go. We have to be specific in legislation that that cannot happen in this instance.”

16 Statement by PACAC 2 June 2016

““We have consistently called for primary legislation to make HSIB fully independent, and to create a credible ‘safe space’ which will enable the NHS to properly learn from past mistakes. Since we approved this report, it is increasingly evident that the Government has accepted this recommendation. The Secretary of State’s decision to set HSIB up as an NHS quango as a permanent response to our recommendations was both disappointing and would be unacceptable, but the prospect of a secure legislative base will enable HSIB emulate the successful air, marine and rail investigation branches.

Were the present non-statutory arrangement to be regarded as permanent it would be an intolerable compromise, disregarding consensus between healthcare experts and Parliament, and would put political dogma against forming new public bodies before patient safety. We therefore look forward to the draft legislation emerging.”

17 The Healthcare Safety Investigation Branch. Glass half full or half empty. AvMA June 2016

18 Keith Conradi’s CV

19 NHS has ‘nothing to fear’ from new investigation body, says chief. Shaun Lintern Health Service Journal 5 January 2017

““The chief investigator will have discretion over what information is revealed but he said: “I think this is one area where I would rather not have discretion. I think ideally in terms of information that is taken under safe space principles we should have an obligation to protect those statements, but the relevant information – and the key word is relevant – is in the report or attached to the report somehow. He added: “We have to remember why we are doing investigations. We are not doing the investigations purely to get information for the families. We are doing it to improve learning and safety; we are not doing it on behalf of the staff, family or any particular body. If safety is improved because somebody opens up to us surely that is the most important thing we can do. If there is relevant information for the family it will be included in the report.”

20 Whistleblowers need more than hand-wringing headlines, Sir Robert