A new national safety investigator for healthcare: the road ahead

The most fundamental principle of patient safety is that we must learn from the past to improve the future. From April 2017, the English National Health Service becomes the first healthcare system in the world to have a specialist agency dedicated to investigating and learning across the entire healthcare system: the Healthcare Safety Investigation Branch. This represents a watershed moment. The use of system-wide, expert-led, learning-focused safety investigation is an essential feature of other safety-critical sectors such as aviation, but has long been missing in healthcare. In this journal in 2014, we set out the case for establishing a national patient safety investigator along with practical proposals for how it might function. That paper triggered a Parliamentary select committee inquiry in 2015 and, after extensive consultation, legal directions and expert guidance for establishing the Healthcare Safety Investigation Branch were published in 2016. Now the real work begins. Healthcare Safety Investigation Branch will systematically and routinely investigate the most serious risks to patient safety across the healthcare system, publicly report on its findings and issue recommendations for improvement. These safety investigations are solely for the purpose of learning and will explicitly avoid allocating liability or blame. The independence of the Branch – still to be fully achieved – will allow it to investigate and make recommendations to any relevant party, including healthcare regulators, equipment manufacturers and education providers – organisations that cannot easily be influenced by other agencies. Building a trusted, respected and effective national safety investigator will take time and the challenges are considerable. Some challenges are technical, such as developing appropriate analytical and investigative methods. But in our view, the greatest challenges facing Healthcare Safety Investigation Branch are primarily social and cultural in nature. These are threefold. First, establishing the legitimacy, authority and independence of national investigative activities. Second, earning the trust and confidence of healthcare professionals, patients and the public. And third, creating systems that constructively support practical improvement across the healthcare system.