New investigation body will help NHS learn lessons from costly mistakes

Many organisations and industries operate rigorous procedures to ensure mistakes are thoroughly investigated and action taken to stop them happening again.

Tuesday, 5th April 2016, 6:08 am

The aviation and nuclear industries are good examples of sectors operating this culture of looking at the mistake, not who is to blame for it.

The reasoning behind this is common sense: it saves lives, money and leads to even better safety.

And it’s quite clear that organisations that do not operate this culture suffer from lives lost, money squandered and less confidence in the safety of their services.

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Sometimes, the NHS has been that organisation and this overshadows much of the excellent work its staff do treating 650,000 patients a day.

Twice a week in the NHS, medics operate on the wrong part of someone’s body and, twice a week, foreign objects are wrongly left inside someone.

Avoidable deaths in the NHS run at about 150 every week.

Such a massive organisation, undertaking so much complex work, needs to ensure it can learn from these mistakes, which cause so much heartache for patients and families.

And if there is to be an improvement in these statistics, then the NHS culture of blame and a lack of transparency and accountability must be tackled.

I therefore very much welcome health secretary Jeremy Hunt’s announcement.

He will set up, from next month, a tough and transparent new investigation body to help lower cases 
of preventable harm and death.

Called the Healthcare Safety Investigation Branch, it is modelled on the successful Air Accidents Investigation Branch and will undertake timely, no-blame investigations.

Importantly, the initiative comes with measures to give legal protection to those who speak honestly to investigators.

This ‘safe space’ should reduce the defensive culture too often experienced by patients and families who complain, and will allow the NHS to learn and disseminate lessons more quickly, so mistakes will not be repeated.

Just as importantly, the results will be shared with patients and families, who will get to the truth of what happened much more quickly.

These are bold moves, broadly welcomed, and will lead to openness and transparency about where problems exist, and a proper learning culture to put them right.

Of course, it’s very difficult to replicate ideas from aviation or the nuclear industry and apply them to something less than exact, like medicine.

But that’s no reason not to try to foster a new culture of openness – to hopefully have fewer deaths, encourage the NHS to learn and allow families the truth.