
HSSIB exists to investigate patient safety concerns so we can improve healthcare care at a national level. At the heart of this is a professional patient safety investigation that helps us to understand how things are done, how healthcare is delivered, and the factors and circumstances that lead to harm. Simply, if we want to understand what has happened, we must speak to everyone involved.
Patients and those close to them, including family members and carers, are the constant in every healthcare journey. Their insights into the care they experience are unique and essential to understanding how work is done, and how that feels for people receiving care.
Our process of gathering information to support our investigation includes listening to all people involved in a patient safety event. If the patient is alive, this will include them, as well as the people close to them. We do this by meeting with them at a time and place they feel safe to tell us their experience. This is often in their home and always at a time that suits them. We stay in touch. We share our findings and help the patient and/or their family understand what happened and what we have learnt. This takes time and often involves meeting and going through the investigation report page by page. We will always adapt our way of working with people, recognising barriers to communication, and working to address these from the outset and throughout. This ensures our engagement is meaningful, not tokenistic, and tailored to the individual.
If we don’t listen to patients and families through consistent and meaningful engagement, we risk compounding harm already experienced through a patient safety event. By doing this well, patient safety investigations can be a collaborative tool to help all involved move forward after an incident with a shared understanding of how it happened and what has been recommended to make care safer for people in the future.
Healthcare inequalities impact care experience and outcome and this can be true in investigations as well. We tailor our approach for people who are often excluded and under-served to facilitate their involvement. By taking the time to include those previously described as ‘hard to reach,’ the patient safety investigation can have an even greater impact, by amplifying voices and highlighting differences in experience. In our recent investigation ‘Caring for adults with learning disabilities in acute hospitals’ we spoke with over twenty people with a learning disability to help us understand what it was like for them when in hospital.
We know from several reports, reviews, and inquiries over recent years that the patient and family voice has not been heard. These voices are essential to learning and improvement because of their unique insight into how care is delivered. To improve safety we must understand its reality as experienced by patients.
Caring for adults with learning disabilities in acute hospitals (hssib.org.uk)
Rosie Benneyworth is interim chief executive officer of the Health Services Safety Investigations Body (HSSIB)