The investigation of stillbirth

This House of Commons briefing discusses the way that stillbirth is investigated at present and the government announcement about independent investigations in future.

NHS told to 'get serious' as full impact of cyberattack revealed

NAO investigation finds at least 139 urgent cancer referrals cancelled after WannaCry cyberattack

Investigation criticises NHS England and DH response, and “absence of timely central direction”

Central bodies were ignorant of NHS’s cybersecurity arrangements and had not rehearsed national response

Nearly 600 GP practices shut down after infection

An investigation into the unprecedented WannaCry cyberattack on the NHS has revealed more than 130 urgent cancer referrals were cancelled and more than 1,000 medical devices were infected.
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Learning from post-accident investigations to ensure patient safety

Jeremy Hunt explains the thinking behind the Health Service Safety Investigations Bill, and recent steps to improve patient safety.

Last week we published the draft Health Service Safety Investigations Bill, which represents a landmark moment for safety and transparency in the NHS, and a victory for the many campaigners who in the wake of the Mid Staffs and Morecambe Bay scandals have called for major change.

The Health Service Safety Investigations Bill aims to take Martin’s insights on post-accident investigations in the transport industry and apply them to healthcare. It will establish, for the first time, a fully independent investigations body responsible for finding answers and embedding new practices across the NHS in the wake of a healthcare error.

New bill to improve patient safety

The draft Health Service Safety Investigations Bill will establish and enshrine in law the powers of the Health Service Safety Investigations Body (HSSIB).

The HSSIB will take forward the work of the current Healthcare Safety Investigation Branch (HSIB), which came into operation in April 2017 as a division of NHS Improvement.

Under the proposals, the HSSIB will be independent of the NHS and at arm’s length from government. It will have far-reaching access to investigate serious safety incidents or risks to patient safety.

How can we assess how well providers review, investigate and learn from deaths?

The CQC would like your views on how we can strengthen the way we look at whether NHS trusts learn from deaths to improve the care they provide.

They'd particularly like to hear from families and carers, but are interested in the views of health professionals too. You can tell them what you think by taking part in our online survey. The survey closes at 6pm on 14 July.

DH publishes response to 'safe space'

The Department of Health (DH) has published a response to the providing a 'safe space' in healthcare safety investigations consultation.

The response outlines feedback received and next steps:

• The new Healthcare Safety Investigation Branch (HSIB) is expected (from 1 April 2017) to conduct investigations using the safe space principles set out in the NHS Trust Development Authority (Healthcare Safety Investigation Branch) Directions 2016.
• In the absence of legislation, the DH is currently unable to subject disclosure of material under HSIB investigations to a general prohibition. The government remains open to considering the option of legislation in the future.
• Only when 'safe space' has been tested and works effectively at a national level, will the DH consider extending 'safe space' to investigations undertaken by on behalf of commissioners and providers of NHS funded services. The DH has outlined three conditions for extension, one of which would be going out to further consultation.

National Guidance on Learning from Deaths

Guidance from NHS England to help standardise and improve the way acute, mental health and community Trusts identify, report, review, investigate and learn from deaths, and engage with bereaved families and carers.

Rapid Resolution and Redress Scheme for Severe Birth Injury Consultation

This PHE consultation seeks views on the proposed investigations into severe avoidable birth injury and the support and compensation scheme. This consultation closes on 26 May 2016.

The Health Foundation has selected eight projects for its new Evidence into Practice programme

The Evidence into Practice programme will enable the selected research teams to use their innovative and creative ideas and translate their findings from completed studies in improvement research, or more broadly in health services research, into actionable practical tools for practitioners in health services or health policy.

Each research team will receive £50,000 for the development of tools and resources to support the implementation of findings into practice. Each project will be funded for 15 months.

The eight projects are:

1. A short animated film and other visual resources to support recognition and response to eating disorders in the perinatal period
Organisation: King’s College London, Institute of Psychiatry, Psychology and Neuroscience

2. A hand-drawn animation exploring accelerating systems thinking in health care incident investigation
Loughborough University

3. On-line tools for GPs to help support new migrants in primary care
University of Sheffield

4. Online resource pack with infographics, videos and downloadable materials on REasonable adjustments to MAINstream diabetes and obesity care for adults with a learning disability (REMAIN)
Leeds Institute of Health Sciences, University of Leeds

5. Online platform dedicated to innovation in breathlessness management (E-Breathe)
King’s College London. Cicely Saunders Institute,

​6. A year in an hour: Quality Improvement through Interactive Simulations (QIIS)
Chelsea and Westminster Hospital

​7. Short videos outlining key messages for better tracheostomy care
University Hospital South Manchester

​8. In Control: a 40 minute theatre piece and workshop to challenge, empower and provoke conversations amongst adolescents with asthma and their peers
Barts and The London School of Medicine and Dentistry, Queen Mary, University of London

Mycobacterial infections associated with heater cooler units

Guidance and investigation updates from Public Health England concerning the risk of mycobacterial infections associated with heater cooler units used in cardiothoracic surgery.

Sexually transmitted infections (STIs): managing outbreaks

Guidance on How to investigate and manage STI outbreaks, published by Public Health England,

Hospital trusts to receive poor CQC inspection ratings for failing to involve families in avoidable death investigations

The Secretary of State for Health, has told hospital trusts that a failure to involve families properly in the investigation of avoidable deaths may result in them receiving a poor Care Quality Commission (CQC) inspection rating.

This follows the report released last week by the CQC into NHS death investigations. The report found widespread inconsistency in investigations of avoidable deaths by NHS trusts across the country. The report also found that patients’ relatives are being left in the dark during investigations about patient deaths.

In response to this report, the government has said that trusts will be required to follow a new standardised methodology and publish the number of avoidable deaths that occur at their hospitals.

Legionnaires' disease: national surveillance scheme

Update on guidance for the control and prevention of Legionnaires' disease in England, including disease surveillance and reporting forms from Public Health England.

See also Investigation of Legionnaires disease: cases, clusters and outbreaks

Learning, Candour And Accountability: A Review Of The Way NHS Trusts Review And Investigate The Deaths Of Patients In England

This national review from the CQC has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens. The report looked at how NHS trusts across the country identify, report, investigate and learn from the deaths of people using their services.

New programme to improve care by reviewing deaths in hospital

A new programme from the Royal College of Physicians will help hospitals in England and Scotland standardise the way they review adult deaths in hospital. The National Mortality Case Record Review Programme has the full backing of the NHS in both England and Scotland.

The aim of the project is to replace the varied systems currently used with a single, standardised, national, evidence based method for mortality review in every acute hospital to maximise the potential for learning and improvement.

Providing A 'Safe Space' In Healthcare Safety Investigations - Consultation

The DH proposal outlined in this consultation will legally ensure that information that staff provide as part of a health service investigation will be kept confidential except where there is an immediate risk to patient safety, or where the High Court makes an order permitting disclosure. This broadly mirrors the procedures followed in air accidents investigations. The closing date for comments is 16 December 2016.

CQC - Our review of how NHS trusts investigate and learn from deaths

We're looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. We also want to assess whether opportunities to prevent deaths have been missed.

Receive an alert when this report is published.

We aim to publish our findings in December. 

GMC to reduce the stress on doctors by piloting fitness to practise changes

The General Medical Council (GMC) has launched two pilot schemes to speed up fitness to practise cases and reduce their impact on doctors.
One of the pilots will involve cases where doctors are alleged to have made a one off mistake involving poor clinical care. Instead of opening a full investigation the GMC will first gather a few pieces of key information about the case, such as medical records and incident reports. Only after reviewing this evidence will the GMC decide whether to open a full investigation, refer the matter to the doctor’s Responsible Officer*, or close it with no further action.

Help improve how the NHS learns from unexpected deaths

When someone dies unexpectedly while under NHS care, it is important that the correct processes are in place to find out why. 

The Care Quality Commission is looking at this issue and wants to hear your views.

An investigation report by the Parliamentary and Health Service Ombudsman into how the NHS failed to properly investigate the death of a three-year old child

The report on an investigation into a child's death, found that the local NHS investigation processes were not fit for purpose, and not sufficiently independent, inquisitive, open or transparent, properly focused on learning, or able to span organisational and hierarchical barriers, and they excluded the family and junior staff in the process.