The Doctors’ Association UK (DAUK) welcomes the publication of the Joint Committee on Draft Health Service Safety Investigations Bill (HSSIB) report. There are 24,000 serious incidents reported annually in NHS England. Current processes for investigations have been criticised for blaming individual members of staff for systemic problems, failing to learn from mistakes and failing to involve patients and families effectively. An open culture that focuses on learning in general, but especially when things go wrong, is urgently required to foster a safer healthcare service for us all.
The Doctors’ Association UK is pleased that the report agrees with our written submission that the provision for the HSSIB to accredit NHS trusts to do their own ‘safe space’ investigations is an enormous conflict of interest. We are therefore delighted that the report has recommended that the entirety of part 3 of the draft Bill, relating to Trust accreditation, be dropped.
The Doctors’ Association UK is also pleased that the report agrees the value of the HSIB as an independent body, bringing medicine in line with the rail and aviation industries. ‘Safe space’ investigations will allow staff to speak freely and determine what went wrong to prevent similar mistakes happening again. If ‘safe space’ investigations are to carry the confidence of the public, the independence of the HSIB must be assured.
The Doctors’ Association UK’s central campaign is entitled “Learn Not Blame”, and seeks to engender a national conversation about the need for a just culture in the NHS. We are campaigning for a step change in the NHS so that honest error is used to drive learning and change for a safer, better NHS, rather than being a focus for individual blame. The creation of a truly independent body is a welcome step towards this.
