ICBs ‘detached’ from patient safety risks

A new reporting system has left integrated care boards “detached” from patient safety incidents, a watchdog has found.

The Health Service Safety Investigations Body (HSSIB) said some ICBs first heard of an incident when they were asked to provide a media statement.

In a report published today it highlighted views that a new reporting framework had “eroded assurance activities and patient safety oversight.”

The NHS has largely moved from the serious incident framework – where incidents were investigated locally but ICBs played a key role – to the patient safety incident response framework (PSIRF), which is less prescriptive about how trusts need to react to incidents and is not based on the level of harm involved.

But the HSSIB report revealed widespread dissatisfaction among ICBs about the new model, with commissioners saying many PSIRF responses did not trigger a report, leading to them having less visibility of risks from incidents.

This was a particular concern when risks arose when patients moved between providers. ICBs were also often uncertain how risks were being mitigated and what providers had done as a result of incidents.

The safety body was also critical of the Learn from Patient Safety Events database, highlighting problems with “the useability and utility of the data”, with one ICB saying it had “3,000 incidents downloaded but no way of understanding them.” Multiple ICBs had escalated issues with this to NHSE as the data was not useful for identifying hazards and risks.

Helen Hughes, chief executive of the charity Patient Safety Learning, said issues with database were “not simply a technical problem with a new digital service.”

“They will result in missed opportunities to identify patient safety risks, learn from them and ultimately prevent avoidable harm to patients,” she said.

“With greater clarity around the roles, ICBs and ICSs have the potential to drive systemic improvements in patient safety. However, to do so effectively, they require enhanced tools, capacity, and a more integrated approach to digital solutions, such as LfPSE, that support patient safety.”

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Source: HSJ, 13 February 2025

You can read Patient Safety Learning’s response to this report here.