The future of NHS patient safety investigation: engagement feedback (November 2018)

Summary

On 20 March 2018 NHS Improvement launched an engagement programme to seek views from a wide range of stakeholders about how and when patient safety incidents should be investigated. Often those affected by incidents are not appropriately supported or involved in the investigation process; the quality of investigation reports is generally poor; and improvements to prevent the recurrence of harm are not effectively implemented. To obtain views on the problems with the current approach to the investigation of Serious Incidents, the issues driving these problems, and how such issues might be resolved, NHSI ran an online survey, national workshops and a live twitter chat, and held discussions with many individuals including patients, families, NHS staff, regulators and others. This document summarises the feedback received.