Maternity investigations to remain outside HSSIB's remit

In April 2018 I reported on the announcement by the former Secretary of State for Health and Social Care, Jeremy Hunt, that the Healthcare Safety Investigation Branch (HSIB) would be extending its remit to investigate 1,000 maternity incidents per year. The maternity safety incidents all related to full term births which took place in England after 1^st April 2017 and resulted in stillbirth, neonatal death or severe brain injury to the babies or death to the mother around the time of the birth (perinatal maternal death).

The announcement followed the RCOG’s Each Baby Counts report’s criticism of the poor standard of local NHS trusts’ maternity safety investigations, 66% of which excluded the family from involvement in the investigation.  I shared my own experience of the additional distress that my clients suffer when disingenuous and superficial NHS Complaints Procedure or Serious Incident Framework investigation of the events which led to devastating injury to their baby or loss of the mother fails to address or explain the true cause of that injury.

By removing the investigation of ‘Each Baby Counts’ eligible maternity safety incidents from local NHS trusts and placing them within the remit of the HSIB, the Department of Health and Social Care (DHSC) hoped that HSIB would use its investigatory expertise to bring a standardised approach to maternity safety investigations whilst enabling learning from mistakes to be shared across the NHS. Patient involvement was stated to be a priority within the investigation process yet HSIB’s investigation reports would not attribute blame.

Parliamentary Committee: maternity safety investigations are not within HSSIB’s remit

Following its recent pre-legislative report on the government’s draft Health Service Safety Investigations Bill the Parliamentary Joint Committee has now condemned the government’s plan to incorporate responsibility for individual maternity safety incident investigations within the new HSSIB’s (HSIB’s new statutory successor) remit. There are good reasons why it was correct to do so:

• HSSIB will be accountable directly to Parliament and completely independent from the NHS and the DHSC. Its remit is to carry out (system-wide not individual) patient safety reviews. Local maternity safety incidents are the responsibility of NHS Improvement, not HSSIB.
• There is a difference between a local serious incident investigation and a (general) patient safety review. Local investigations into maternity safety incidents are meant to uncover what happened clinically and to provide explanatory information for the family about their own experience. A (general) patient safety review provides recommendations for improvement arising from common mistakes identified across the healthcare system. It is not part of the NHS complaints system.
• HSSIB’s remit is not to replace existing local serious incident investigations or patients’ rights to an investigation, explanation, apology and compensation for what went wrong in any particular incident. Its investigations are additional to existing investigations for the purpose of making recommendations to improve patient safety. 
• The Committee said that if HSSIB carries out local investigations in place of NHS trusts there is a risk that trusts might be prevented from fulfilling their current responsibilities following the occurrence of a serious incident. For an organisation to be properly governed and to be held accountable, it must have appropriate oversight and control of its operations…for the benefit of patients, their families and staff, as well as to reduce duplication and risk. HSSIB shouldn’t and cannot take on that role, but neither can the trust do so properly if it is merely an observer.
• HSSIB’s (general) patient safety reviews will have ‘safe space’ protection from disclosure. Individual maternity safety incident investigations are local investigations into individual incidents and are not carried out under ‘safe space’:

  “The imposition of 1,000 local maternity investigations outside of ‘safe space’ risks completely misconstruing the function of the statutory HSSIB…with the potential to distort the perception of what HSSIB is for, within the health sector. We are concerned that HSSIB should be understood across healthcare. Its purpose and function is the conduct of ‘safe space’ investigations of incidents without finding blame in order to promote patient safety and learning. It is not an organisation to be tasked by others to deliver local NHS investigations”

While it is commonly accepted that the standard of maternity safety investigations within NHS trusts needs to be raised for the benefit of patients, maternity staff and the NHS as a whole, the Parliamentary Joint Committee has made it absolutely clear that DHSC and NHS Improvement cannot simply “task” HSSIB with sorting them out. 

Learning from maternity safety incidents is a key priority for the NHS if the unacceptable scale of suffering and associated costs arising from 1,000 maternity safety incidents each year is to be reduced to meet the government’s target of 50% fewer severe birth-related brain injuries, maternal deaths, stillbirths and neonatal deaths in England by 2025.  Inclusive, thorough, impartial and transparent investigation of maternity incidents is critical if causes of harm are to be identified, learning to take place and patients’ trust regained after these tragic and damaging incidents occur.

In the lead up to the draft Health Service Safety Investigations Bill’s passage through Parliament, we  await the DHSC and NHS Improvement’s proposals for how maternity safety incident investigations will be handled in future.

If you or someone in your family has suffered maternal death or brain injury as a result of medical negligence around the time of birth, contact us by email on cerebralpalsy@boyesturner.com.