David Czarnetzki
On 1st August, PHSOtheFacts published my blog “Health and Care Bill – Another layer of confusion”. In the blog, I attempted to identify flaws in the Bill now going through parliament. This included the fact that there is to be a protocol between the Health Safety Investigation Branch (HSSIB), created by the Bill and the Parliamentary and Health Service Ombudsman (PHSO). I sent a copy of the blog to Keith Conradi who heads up the HSIB.
In the interest of openness and transparency, I publish, with Mr. Conradi’s permission, his letter of reply.
Before commenting on the content of his reply, it is worth drawing attention to the courteous nature of the correspondence and contrasting it with the arrogant email response from PHSO published in the blog of 25th June on this website under the title “Who do you think you are kidding Mr. Behrens?”
Mr. Conradi has outlined his view on how he envisages the new HSSIB will work.
However, the current wording of the bill, addressed in the 1st August blog, does not enshrine the HSSIB/PHSO relationship in law other than to state that HSSIB will be an organisation added to the list which can be investigated by PHSO, yet they have to set ‘protocols’ so as not to tread on each others toes during health investigations. There is already in existence a protocol between the HSIB and PHSO due to expire in November this year as Mr. Conradi has explained.
As has been pointed out to me, there are additional issues:
- Who will make the decision?
- What say will patients have?
- How will patients know whether the issue they raise is systemic and should be addressed by HSSIB or incidental and investigated by PHSO (having first gone through the internal complaints process of the hospital concerned)
- HSSIB investigations cannot be used in evidence in order to provide ‘safe space’
- What will PHSO do if a hospital decides to report itself to HSSIB for a systemic failure? I suspect it will stand back.
- How will this relate to the Care Quality Commission’s terms of reference?
This aspect of the Health and Care Bill has to be of concern. It seems a classic case of legislation designed to lull the public into a false sense of security that something is being done to improve patient safety, whilst denying complainants a simpler course of redress for clinical mistakes other than the tortuous route of suing for negligence.
Politicians might genuinely believe this improves patient safety. I fear it will become just another horse on the merry go round.
It will not improve access to justice when secrecy is the overriding priority.
Is my complaint systemic?
Do I want to use the evidence in future legal action?
phsothetruestory 
Hsib is developing good reports with wide ranging calls for systemic improvements and thematic reviews and involving patients. I especially draw people’s attention to asthma in children report , cauda equine recent report and the recent thematic review of 22 investigations and call for a safety system. I believe the frameworks being developed may be useful to aid patients and families demanding proper learning and system changes from harm events
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HSIB is another con so people think they actually do something. They investigate what they are told and are part of the cover up process because many serious issues are conveniently never taken up by them.
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Below links about The other new reporting system which will have a patient family portal some time and also other patient involvement developments…I agree it is not enough …safety and patients vital unique often fearless contribution should be embedded at every level as Berwick concluded
And
https://www.england.nhs.uk/patient-safety/framework-for-involving-patients-in-patient-safety/
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You are correct there is no investigation system for systemic complaints but HSIB and also the new reporting system (more below) will logging issues…..
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I can’t see anything where the patient gets compensation for clear negligence. I would not attempt to go through any of the procedures as I know they are all absolutely fake. 2 MP’s could not even look at evidence for fear of embarassing the NHS.
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But who identifies this systemic risk?
Phso does not have the skills or traing needed even for one case evidencing serious issues, and systemic problems with Phso complicates and obscures matters.
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Some research being done
https://yhpstrc.org/research-themes-partners/patient-involvement-in-patient-safety/
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Thank you Richard. There is always work being done to improve patient safety and that is to be applauded. However, the theme of my two blogs concerns the lack of accountability of both HSSIB and PHSO contained in the Health and Care Bill currently before parliament.
As currently written, the Bill creates the new HSSIB which will have protocols with PHSO concerning investigations. Hidden in the depths of the Bill is the fact that HSSIB will also be a body subject to investigation by PHSO. Based on the vast range of experiences aired on this website, Trust Pilot and in Della’s book “What’s the Point of the Ombudsman”, no matter what altruistic intention the Bill might have, it is unlikely to inspire confidence in the public as it is currently written.
The problem is that the public will only identify the flaws when becoming embroiled in the system and, in most cases as some of us have found out, that is too late.
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https://www.england.nhs.uk/patient-safety/incident-response-framework/faqs/ follow them on twitter too https://twitter.com/ptsafetyNHS?s=09
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Frustrations of patients and families that no body apart from HSIB is tasked to investigate possible nhs system failings causing harm are very real serious anda hugehole in patientsafety if patientsareto be listened to as berwick recommended. The only other route is via a new updated patient reporting system, building on the old NRLS, currently being worked on by nhsE/I patient safety team. Also work is being done by researchers in Bradford on more involvement of patients in serious incident investigations
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It seems to me that Keith Conradi hasn’t fully examined the issues involved here, and I can understand why he wouldn’t as it is Parliament’s job to sort out these issues, and they have made a very poor effort to date. Most tellingly, it seems to me, is that Keith Conradi has claimed that “HSIB does not investigate individual complaints – it investigates systemic patient safety risks”. But as David points out, an individual complaint can also be a systemic patient safety risk. What happens then?
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CQC are a waste of time and their inspections have specific parameters that avoid digging into patient safety incidents. Whilst Trusts mark their own homework, Doctors have responsible officers they know and work with nothing will change for the old boys network.
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