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New Patient Safety Rules Mean Some Hospitals 'May No Longer Investigate'

A new system for dealing with incidents that cause patient harm may mean some NHS trusts will no longer hold investigations when they still should, warned the chief executive of the Parliamentary and Health Service Ombudsman (PHSO).

A new NHS Patient Safety Incident Response Framework (PSIRF) comes into force this autumn and is intended to look at how patient safety incidents happen so that learning can be more effective. It will mean trusts can carry out alternatives to a full investigation, such as a team review of what happened or a "swarm huddle", where staff gather to quickly analyse what happened and decide how the risk can be cut in future.

According to a new health service ombudsman report published on Thursday, the PSIRF is intended to "allow organisations to focus resources on where they can really make an impact, rather than having to always conduct an investigation where that might not lead to new learning or create change".

While PHSO chief Amanda Amroliwala said the framework will support learning and accountability "in those trusts that already have a culture of openness and honesty", she said one "difficulty is the framework does give more flexibility".

She added: "So, if you are already an organisation that doesn’t have that culture – and that has a culture of defensiveness and an unwillingness to think that something’s gone wrong – there is the possibility that you may not conduct an investigation when you should have done so."

She said things such as swarm huddles would not be recorded "in a formal way that you would expect from a serious incident investigation".

She added: "So, I think this is something that the new integrated care boards (ICBs) will need to look at, and I think there should be a responsibility for them to look, if an organisation is otherwise being considered as one that needs extra support or that is not performing, and I think that’s something that will need to be looked very closely – which is, have the number of incident investigations declined since the framework came into place?

"And if so, how can how can that be accounted for? And does that mean, actually, that things are being done in a more agile way that is to the benefit of families and patients? Or is it not?

"And I think that’s something that we will all have to keep a close eye on as the framework rolls out."