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Summary
Richard von Abendorff, an outgoing member of the Advisory Panel of the Healthcare Safety Investigation Branch (HSIB), has written an open letter to incoming Directors on what the new Health Services Safety Investigations Body (HSSIB) needs to address urgently and openly to become an exemplary investigatory safety learning service and, more vitally, how it must not contribute to compounded harm to patients and families.
The full letter is attached at the end of this page.
Content
HSIB as experienced and observed vs HSIB as imagined and described (and not researched!): a patient system perspective
Dear Ted and Rosie and all incoming Directors to HSSIB,
In 2017 I wrote an open article making demands of HSIB to be patient centred. Six years later, having following HSIB closely, and in some aspects intimately, I write an open letter from a point of despair as HSSIB emerges from HSIB and I end my formal involvement as the patient safety expert from experience on the Advisory Panel. Nothing I say may surprise you, but I hope the incoming executive considers these issues seriously and urgently.
I raise it in this public way as I believe if these issues are not transparently and explicitly addressed as a matter of urgency, I cannot assure other patients and families should they become involved with HSSIB. I say this for fear they will experience compounded harm and, related and additional to this (as I will expound below), I have significant concerns about the quality and output of HSIB investigations to achieve maximum impact, utilising the patient and family perspectives.
HSSIB must prioritise its development to become exemplary and better than what has gone before (based on evidence) and to also be valuable not harmful for patients and families. Patient safety in England needs a place where trust and faith are restored, with evidence showing it listens, learns and acts by putting patients and their advocates at the centre.
The issues can be examined from three perspectives relevant at this juncture:
- A review of its past work given it has new power.
- The new governance arrangements coming in to place, but without patient voice at its heart.
- Various concerns over the last 6 years that cannot be ignored, and a recognition already acknowledged by yourselves, Ted and Rosie, that the patient involvement aspects require more work.
My full letter details the experiences I draw upon.
I challenge the lack of evidence base and research on HSIB that claim it is truly independent drawing on patient and family perspectives. I do not go in to detail on other publicly shared criticisms of HSSB, but I believe these criticisms cannot be ignored and have not been adequately addressed.
I bring to everyone’s attention that the Advisory Panel I was on had no explicit or expected role in even commenting on these types of issues but some members did at times. Given Governance at HSSIB is now being established in a more recognised, explicit and conventional way, I believe the Non-Executive Directors and Executive Directors have a vital role to immediately address these concerns drawing on independent expertise.
I challenge the opinion that HSIB has an innovative or patient-centred engagement model. It focuses on the important issues of accessibility and basic, respectful communication with patients and families – something we have seen that has not been done by health bodies. But it does no more than this. This is not exemplar family involvement.
The letter relates independence to patient-centredness in a way contrary to how HSIB has worked in the past and refers to the vital need to report authentic accurate accounts of patients. It argues that much work has to be done to avoid bias towards health service perceptions, and to make patients and their advocates more central in all HSSIB processes, from scoping to evaluation.
Family involvement is so much more than engagement. And in all these processes, patients need not only empowerment but advocacy and support. If HSSIB does not do this, who will give it the recognition it needs?
The letter looks at the relationship between restorative approaches and investigations and how to minimise or, ideally, eliminate compounded harm and to get quality investigations drawing on the valuable insights of families and the patient-led framework that is needed. This itself deserves ongoing research, development and typologisation.
Engagement with whistleblowers in the NHS, and indeed within HSSIB, as a starting point to be any kind of exemplary service also requires explicit, transparent, evidence-based attention given HSIB’s previous history of this (and some key issues are identified in the letter).
The letter recognises the innovative and challenging role HSSIB takes on and that it cannot shirk from addressing these if it seeks to be truly innovative.
However, based on experiences to date, unless HSSIB urgently takes on this challenge, I cannot express any assurance to families who consider participating. I have been a critical friend for a very long time and now can just be a serious critic in making these challenges.
One big question remaining is why these limitations still exist after more than six years of HSIB? One issue has to be to move away from a solely or predominantly technocratic and medically centred and medically organised framework. This also requires consideration.
Richard von Abendorff, 12 October 2023
Download the full letter here or from the attachment at the end of the page:
About the Author
Richard is an outgoing member of the Advisory Panel of HSIB since its inception, a member of the recently disbanded Citizens Partnership of HSIB, a campaigner and a family member involved in a reference case of a national HSIB investigation.
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