Healthcare Safety Investigation Branch Annual Review 2019/20

Summary

The Healthcare Safety Investigation Branch (HSIB) has published their third annual review. During 2019/20:

• 109 patient safety referrals received.
• 515 maternity investigation reports completed.
• 15 national investigation reports published.
• 58 national safety recommendations made.
• 88% of families engaging with the maternity investigations and 87% with the national investigations.
• Family information available in over 20 languages to ensure greater inclusivity.

Keith Conradi, Chief Investigator, said: “There has been a huge amount of hard work from everyone within the HSIB during this period and I want to thank them and acknowledge the support of our stakeholders in the wider healthcare sector, and in particular to all the organisations who responded promptly to our safety recommendations.”

Content

Notable achievements

• Working with the Office for Product Safety and Standards and the British Standards Institute to produce a guide to best practice for manufacturers and retailers of button and coin cell batteries.
• Instigating the Royal College of Paediatrics and Child Health and the Royal College of Emergency Medicine to produce a comprehensive guide on button battery ingestion in children covering common signs, symptoms and critical care situations.
• Recognising the importance of digital technology in healthcare by making multiple safety recommendations, nine to NHSX, across a number of our investigations. In our investigations with a digital impact, we discovered there were no standards for system interoperability for medication messaging; that a standardised digital care passport should be developed with a particular focus on supporting patients with autism; and, that there should be better electronic record sharing between the prison health electronic record system and the custodial services system.
• In the report ‘Design and safe use of portable oxygen systems’ one manufacturer decided to act quickly on HSIB's report’s safety recommendations and developed a new component to improve safe delivery of oxygen to patients.
• 88% of families engaging with maternity investigations.
• HSIB's maternity programme highlighting eight areas of learning from our initial investigations which will be developed into thematic national learning reports and published during 2020/21 (‘Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B’ report already published).
• Strengthening our collaborative working relationships with trusts and maternity stakeholders including, the Royal Colleges, Maternity Transformation Board, NHS Resolution and others. The relationship ensures that trusts are immediately informed when there are safety concerns, and actions implemented so similar incidents can be prevented from happening again.