A report from the genesis of HSIB. Patient centred at heart?

by Richard von Abendorff and Vanessa Wood
 Report and reflections from a meeting with Keith Conradi and Jane Rintoul (seconded from Department of Health to HSIB) comments invited
Summary:

KC and JR said are dedicated to going beyond consultation for consultation’s sake and genuinely want to engage with patients and families in the pursuit of their sole agenda which is to bring about learning from events. They are in the process of considering the range of aspects of their organisation structure and methodology, not least the criteria for selecting the 30 cases a year for investigation from those that are submitted by any stakeholders via the upcoming website, and this includes families. They are charged with the task of remaining independent and will establish an advisory board to ensure that this is the case. They are also charged with the enormous task of acting as an exemplar and positively influencing the quality of investigations conducted by other NHS bodies. They feel that currently, the best way to do this is to conduct exemplary high-quality investigations themselves which are noted for their integrity.
They aim to organically test their methodology within a range of settings to ensure that it is fit for purpose across the NHS and will be initiating such investigations on initial cases after their launch in April. KC gave an impression of a real desire to get this right, bringing independent and fresh investigatory knowledge and indeed integrity from the air traffic investigation sector.

We urge everyone to contribute to the blog to feedback on these ideas and what more they believe needs to be done to give HSIB the best chance to actually address the serious pressures they will face in the restricted context they have been placed.

We urge HSIB to respond explicitly, transparently and fully to these issues as soon as possible to ensure serious failings that many of us have endured, some of which underpin the comments here, can be a force for learning and real change starting with HSIB.
 
 
Fuller notes of discussion and points raised:
Introduction:
The author (RvA) was invited to meet KC and JR and went together with Vanessa Wood (who has been on a similar, very recent journey to the author via the Hospital Complaint &  Harm Investigation system and PHSO). The purpose was to communicate the essence of their personal stories, the essence of the blogs demands and feedback to it from others and to gain information as to what HSIB was doing. We wanted a recording, to allow fuller notes, but KC felt he could speak more freely and openly at this stage without the use of that facility. These notes are what result and hopefully will stimulate more debate on this blog.  Please leave your comments below. 
 
Brief update:

The big message was there was to be an HSIB website launch (an initial version) with lots of information and referrals would be accepted from the end of March. There had been consultation with ‘the big stakeholders’ and unnamed whistleblowers and patients. It later emerged about 10 investigators have been appointed. When we inquired if a patient family advocate was on the panel JR confirmed it was Martin Bromiley. We did clearly express the view that the lack of transparency to date on any of these processes and ‘the usual’ top down appointees by the ‘great and good’ gave no reassurance that a new way of doing things, a new open culture was being modelled by HSIB .
 
 
Blog and feedback to the process:

JR was very clear they found my previous blog useful and wanted to hear as much as possible about feedback from patients, families and whistleblowers to it. We urge everyone who read it and contributed by email, twitter or other to do it via the blog as only some key points were passed on as some will see below. Some people are making very serious contributions via websites and twitter e.g. Whistleblower Dr Minh Alexander and Alexander’s Excavations
 
RvA said that a number of prominent complainant and whistleblower campaigners had been forthright about how they were very sceptical about the whole HSIB project, its progress to date and its potential, given:

1) the lack of any historical review of cases to date so no lessons were learned from past scandalous treatment of patients, families and whistleblowers which meant a number of people could not take part or offer support. As one person said ’we can’t just draw a line in the sand’.
RvA suggested this could be, in fact, must be, made part of the scope of the HSIB who at a very minimum should:
·        comment on the Experts Groups demand for an independent commission (as in the case of KC’s comments of safe space extension beyond HSIB-which he had strongly publically opposed),
·        offer to advise or contribute to this, as it would be HSIB who would need to hear and integrate lessons learnt from this into their  and ultimately others processes
·         Related to this in opening comments RvA has stressed how families should be seen as they were, not only as traumatised victims, complainants, but also experts by experience (of patient needs, care provided and failings in systems) and as  advocates of patients (sometimes in a legal capacity) and crucially as key  witnesses to events. KC said how shocked he was how families evidence was so often ignored compared to how eye witness evidence was used in air accident investigation,  even if the meaning and emotional context to testimony meant it had to be more deeply probed. VM commented how this contrasted with the treatment of health bodies’ evidence, like the legally crafted statements of medical staff and medical notes, not ‘objective’ records of facts, and sometimes ‘doctored’ which were accepted. 
2) Some feedback to the blog urged that enough information has already been submitted to the Expert Group over  18 months ago and needed full consideration by HSIB involving leading campaigners  e.g. based on the Bristol Histopathological Inquiry and  Bristol Paediatric Cardiological  Services risk summit.
3) Concern was also expressed about some ‘national stakeholders’ involvement when they have financial/contractual relations with key bodies that need reform. RvA and VW also expressed their varied personal experiences of bodies like Health Watch, CQC and CCG’s and leading charities in their capacity to respond adequately to major concerns raised by families about services.
4) Some feedback, in essence, suggested it was the corruption of systems and processes and political pressures and not mere incompetence or lack of resources that led to poor investigations. RvA suggests there are many serious pressures and understandable concerns of patients and whistleblowers and this reiterated the need for close scrutiny of how investigations are currently done and why they fail.  Fearless exposition may mean challenging conclusions and actions need to be taken. Learning is the core issue for HSIB
 
 
Human factors and learning:

KC confirmed that Human factors experts are involved because Human factors analysis are so very important at all levels in the system and while the AAIB use of human factors was only very recent they have really realised the value of it in an investigation.
The reason for the investigations is to improve learning- not to do it or act on behalf of staff or families. They will say ‘let’s have a look at these systems’
As they only have a budget for 30 cases, they tried to develop criteria and this has been to think about how these cases can be identified. Drawing on nationwide data systems as they don’t have any data themselves as starting from scratch. They are looking for people to point them in the right direction- they want to open doors to take info in. Criteria include looking at how serious in terms of a nationwide problem any event is and whether there is public confidence in the way it’s being investigated at the moment. They are charged with not doing historical investigations They will make their main focus those which occurred after April as a trigger.
They are looking to use their investigations to set an exemplar- they need to do investigations first to get experience, then check their model is working i.e. does it fit all processes and contexts e.g. mental health and community as well as hospital? They will be refining processes over a period of time, then they can look at how an investigation should be done and we urged the need to relate this to how and why they are done so badly for so many by trusts, PHSO and even NHS appointed Inquiries like in Bristol
In AAIB lawyers tended to circle (from both industry and family) after the report came out- the AAIb didn’t mention names- just lessons learnt without mentioning specifics- you can’t stop operators operating and things will be happening in parallel investigations too, such as inquests.
Who is consulted depends on the evidence and the incident. Need to talk to many including families,  staff and also at times to people who set the regulations- these will be evidence led investigations.
As HSIB has consistently said they will be a learning body it was also suggested by RvA they as a body and participants should be more explicit in spelling out the learning and follow-up actions. Both KC and JR, with very different backgrounds were still to make in their journey setting up HSIB. It may provide vital insights for all other bodies wanting to improve their investigation- for- real- learning capacity. Self reflective learning once again sorely missing in current defensive systems.
 
 Advisory board, patient input and consultation:
 
Board to be set up and appointment process to be published soon- terms of reference in the directions from Hunt are to monitor and check independence. Research of outcomes will also be commissioned they are aware. Being under NHS Improvement for pay and rations they know needs to change and are pressing for greater independence. They want representation from the major players on the advisory board which will be small.
Regarding patient advocates they were aware of the patient public voice group at the NHSI patients safety and want to use that group as a sounding board- JR to run workshops with that group. JR said their appointment had been quite ‘open’. As a recently appointed  PPV himself RvA fedback that while a very useful group of people he did not see its appointment as ‘open’ as JR implied, and as RvA  argued in the blog  care had to be taken to ensure Board appointees and appointment process was much more transparent and open as many campaigners were extremely concerned about the fact that all these bodies and reviews were conducted by those appointed by DoH, NHS England and the ‘safe hands’ they usually work with . Real independent candid and challenging clout was required on any board. An unasked question was what appeal and complaint processes were there and whether PHSO would have a role?!
The recent controversy over the Just Culture task Force referred to in the blog was quoted as an example of a way not to proceed. There was also discussion about the dangers of the usual full-time patient advocates who circulated in the system. The website will have info on the advisory committee investigators biographies etc. when going live.
Stakeholder involvement- how they can continue to be fed into the process themselves. Jane is going to devise some carefully crafted questions as a start which will be put out to us to answer on things they want to elicit views on. RvA emphasised that other key and independent stakeholders like leading family campaigners (e.g. those supporting Bristol families) and independent named whistleblowers (e.g. Dr Alexander) should and must be consulted now. The old adage of fair full consultation at an early stage must not only be done but be seen to be done. The lack of evidence of this was very concerning to us.
But there was explicit recognition for the need for whistleblowers in the process but no further discussion on this.
 
Consultation- who with and what does it look like?
RvA was reassured that in contrast to the poorly received expert group family consultation the same company would not be used this time.  The learning process is on-going.
 Selecting cases – JR is mindful of managing expectations of patients and families as well as all other referrers as they are aware they will have many making referrals.
Road testing methodology- they want to take it and test protocols and will not necessarily pick the first ones. They want to go into all kinds of settings e.g. community, primary care, mental health etc and see if the methodology works.
They invited us to help test the website That will be the route for referral. Jane has been looking at referral vehicles such as PHSO and the forms used. They are developing the forms at the moment. They beg patience while they refine the process.
There will be Patient and family support throughout the investigation process. RVA asked if this would extend to Board level to ensure feedback and support. KC said all the families and next of kin will get a chance to feedback on the report before the publication and right at the start they will meet with families to explain the process and their involvement. KC himself will need technical aspects of the reports explained to him as non-medical so that he can assure himself the report and findings are robust and also thinks families might want this explanation too. He also thinks in complex cases a face to face meeting would be warranted with families or patient. It will important to explain what their part is and how it is different to everyone else that might be involved  i.e. coroner etc.
 
RvA was relieved that families could make referrals to HSIB direct.
Feedback to HSIB:
 
·         the National reporting system essentially totally relies on hospital incident reports, with the inevitable and empirically proven limitations of this
·         how patient reports even when accompanied by excellent witness evidence, protocols  breached, coroners reports, or expert reports are so often totally ignored and the current system of reporting complaints, PHSO and the NRLS portal are not adequate to the task (although a NHS Improvement project may be working on the latter soon)
·         if not taken on by HSIB it should as a triage function to try and offer referral of cases to other bodies(RVA recounted that the only reason he was perhaps at the table of HSIB is that his commissioned expert report of a drug risk was only finally taken seriously by a safety committee of the Royal College of Anaesthetists) approached on his own initiative without help or advice fron any recognised body.  Clear safety issues need more avenues for reporting and consideration-HSIB will only take on a minute fraction.
 
Influence and wider change:
 
As to how to influence investigations in other NHS bodies local and national, by doing a great job themselves that will make the most impact. HSIB come with no agenda but to bring about learning from events KC repeatedly said this as his key message. He said he is not medical or NHS so comes without that baggage which is an advantage.
Furthermore, HSIB can only make recommendations, not able ensure that they are implemented.  They can’t be on bodies such as NICE as they need to be independent of them but they would observe various bodies( e.g. the safe anaesthesia liaison group of the Royal college of anaesthetists). They needed to work smartly- think smartly- trying to be as clever as they can to maximise the impact of their findings and recommendations. VM said psychologists can help with this- asked what type of psychologists they had- they said one involved in change management and another – then Keith said we can tap into the specialisms of stakeholders re particular issues. RVA suggested like PPV sometimes are asked via the safety response panel asked to consult other bodies, e.g. patient facing organisations and their members who were experts by experience.
 
Scope and types of cases:

RvA pushed one personal point how the scope of HSIB should be extended further at this stage even if most cases taken on would be ‘new’.  HSIB had to grasp fully the nature of the current investigation system they were trying to intervene in. Given 99.9 % of families unhappy with complaints, most harm related, would go through the PHSO system, with a new Ombudsman Rob Behrens abut to come in post and draft legislation being discussed surely it was suggested HSIB should devote some resources to examining how the current system worked and why it didn’t for too many. VW and RvA experiences were a testament that well evidenced and externally expertly validated major harm events could be shrugged off with totally inadequate by PHSO investigations.

For balance RvA also added that NHS appointed investigations could show the same massive failing as demonstrated in Bristol last year when in contrast it was PHSO in this case able to show how many serious failings were demonstrated in the tragic death of Sean Turner, covered by Shaun Lintern in HSJ, overturning a NHS England appointed review process.
Based on their own experience, RvA and VW also pushed for one group of patients they believe need to be part of a prioritised group for investigation.  Namely, more complex and multiple morbid hard to assess/treat cases which quickly became ‘palliative cases’ and died, (not treated in hospices or specialist geriatric settings) but whose last days were managed in acute hospital  settings, complex and complicated issues around capacity and consent, lifesaving  versus palliative interventions including concerns about use of opiates, and the role of specialists in acute settings.
Another focus of work suggested by RvA for HSIB was the still remaining poor investigation of never events and other failings raised in national safety alerts, exemplified by the recent nasogastric tube safety alert which had to be targeted at governance and Board level. Incidents like this and how to investigate and learn from them need to be a focus. A recent editorial of BMJ Safety by Trbovich urged for system changes and not simply safety alerts. This would seem a clear example. 
Please feel free to leave your comments.  All will be responded to. 
 

 
 
 
 
 
 
 

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4 comments

  1. dms91

    Excellent account of HSIB. Will it survive the fact Dr Mike Durkin has left NHS England where he was Patient Safety Director and founder of IPSIS (pre HSIB)?

  2. dms91

    As Dr Durkin once told me, ‘Parity of Esteem is just a catchphrase meaning different things to different people’ Is it?

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