Draft Health Service Safety Investigations Bill: A new capability for investigating patient safety incidents Contents



1 Introduction

The draft Bill

Who this report is for


Our inquiry

Report structure

Definition of terms

2 Purpose of HSSIB

Independent patient safety investigations

An independent capability

Learning centred investigations

Enforcement of recommendations

Culture in healthcare: attitudes and behaviours

3 The ‘safe space’ (the prohibition on disclosure)


Justification for the ‘safe space’ (the prohibition on disclosure)

The desired outcome

Likelihood of achieving the desired outcome

Other justification

Other perceived effects of the ‘safe space’

On patients

On the duty of candour

Relationship with duties of NHS trusts and other bodies

Material protected

Extent of the ‘safe space’ (prohibition on disclosure)

Information not leading to an investigation

How safe is the ‘safe space’? (Exceptions to prohibition on disclosure)

When HSSIB should be able to disclose

What should be disclosed

Exceptions outside the draft Bill

Use of information for patient safety reasons

Use as evidence in court

Freedom of information and data protection

4 ‘Safe space’ investigations by accredited NHS trusts

Accreditation of trusts

Conflict of interest

Local ‘safe space’ investigations

Supporting best practice

Clarity of purpose

5 Scope of HSSIB and the additional 1,000 maternity cases

Maternity investigations

Limitation to NHS services

Independent sector

Social care

HSSIB’s territorial scope

6 Powers and procedures of HSSIB

HSSIB investigations: criteria, principles and processes

‘Qualifying incidents’

Consulting on the criteria for investigations

Involvement of patients and families during HSSIB investigations

Co-operation between HSSIB and other investigative bodies

The potential for parallel investigations

A duty to collaborate?

The distinct purpose of HSSIB

Power to interview witnesses

Compulsion of witnesses

Attendance of a colleague or union rep in interviews

Penalty for non-compliance

Powers of entry and inspection


7 Governance and accountability of HSSIB


Governance and accountability

Reviewing the effectiveness of HSSIB

Conclusions and recommendations

Appendix 1: Members and interests

Appendix 2: Call for Evidence

Appendix 3: Schedule of technical drafting / legal points

Appendix 4: Responsibilities and processes following a healthcare incident

Appendix 5: List of abbreviations

Formal minutes


Published written evidence

Published: 2 August 2018