Strategic Learning and Implementation Framework

Decision

The timeframe for the request (both 2013-2019 and 2013-2024 are mentioned in Questions 4 and 10 respectively) includes a time when HSSIB was not in existence.  HSSIB can only provide data from 1 October 2023 onwards as HSSIB is an independent arm's length body that came into existence on 1 October 2023.

The former body Health Services Investigation Branch (HSIB) was in place between 2017 and 30 September 2023 and was hosted by NHS England. Therefore, data for the years requested which are pre 1 October 2023 will be held by NHS England.

Further details can be found on the HSIB legacy page, which explains the difference between HSIB and HSSIB.

NHS England can be reached on: england.contactus@nhs.net.

1) Follow-Up Processes: What specific processes does HSSIB have in place to follow up on recommendations made in their reports, particularly those related to mental health deaths?

The Health Services Safety Investigations Body (HSSIB) operates under the legislation set out in the Health and Care Act 2022 (HCA 2022). HCA 2022 Part 4, Sect 116 cites ‘the person must respond to the HSSIB in writing setting out the actions they propose to take in pursuance of the recommendations’. However, no role is set out in the legislation in relation to monitoring or follow up. Currently HSSIB do not monitor implementation of the recommendations made within their safety investigation reports.

However, the HCA 2022 also cites that ‘HSSIB may publish the response’, which we do – these are all available to view on our website.

Over recent months HSSIB has piloted a process to monitor implementation of recommendations it has made with an anticipation of assessing impact of implemented recommendations in due course.

2) Integration of   HSSIB  findings: How does HSSIB integrate findings from:

• Independent mental health homicide investigations and independent inquiries commissioned by NHS England?
• Domestic Homicide Reviews (DHRs) commissioned by Community Safety Partnerships (CSPs) under statutory guidance from the Home Office?
• Investigations and reviews conducted by the Healthcare Quality Improvement Partnership (HQIP), such as those by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)?

Additionally, are there any formal partnership agreements or memoranda of understanding between HSSIB, HQIP, NHS England, CQC or Community safety partnerships/Home office?

How does HSSIB triangulate investigation recommendations made by other statutory agencies e.g.  HQIP-commissioned work, such as NCEPOD reviews, with their own findings to ensure comprehensive and cohesive recommendations?

Are there any formal memoranda of understanding or partnership agreements between HSSIB and these statutory bodies?

HSSIB investigations consider a wide range of evidence appropriate to every investigation. HSSIB has published four reports into aspects of mental health care:

• Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning
• Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings.
• Out of area placements.
• Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services.

Additionally in January 2025 HSSIB is scheduled to publish a further mental health report - Creating conditions for learning from inpatient mental health deaths and near misses in inpatient and community mental health services. All the above reports are/will be available on our website.

Across all these reports we have engaged with national, regional, and local healthcare organisations, including the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), NHS England, the Care Quality Commission, Integrated Care Boards, Independent care providers and local acute trusts. The engagement has been specific to the topic of care being investigated – none of the investigations have focussed on mental health homicide.

HSSIB has dedicated Memorandum of Understandings (MoUs) in place with NHS England, the Nursing and Midwifery Council and the Human Fertilization and Embryology Authority.

Our investigative evidence base includes many reports that other organisations have published; this includes recommendations they have cited. Across the mental health investigations, the evidence base cites more than five hundred references (each report details the respective reference used).

The HCA 2022 provides HSSIB with powers of seizure, compulsion, and entry. HSSIB investigators also have powers to require information be shared (HCA 2022, Part 4 Sect 119). HSSIB has not had a reason to invoke these powers to date and has operated in line with HCA 2022 Part 4 Sect 120 (Voluntary provision of information).

2) Comparative Analysis:

a. Has HSSIB conducted any analysis comparing their findings and recommendations to those in the Niche compendium of learning thematic review that scoped 40 mental health-related homicide reviews or those  from the NCEPOD  studies relating to mental Health services. If so, what were the results?

HSSIB has not conducted specific comparative analysis with respect to the Niche report. Our mental health investigations have not focused on mental health homicides, we are an independent safety investigative body who operate under the legislation defined by the HCA 2022. HSSIB decide what aspects of health care provision to investigate (except where the Secretary of State directs HSSIB (HCA 2022, Part 4 Sect 111).

3) Consistency with McCallion Review:

HSSIB became operational on 1 October 2023 and is a non-departmental arm’s length body who operate independent to all other healthcare providers. HSSIB is required via the HCA 2022 to publish its investigation selection criteria, this can be found on our website.

5) Alternative Investigation Models

a) Has HSSIB considered adopting a multi-agency review approach similar to Domestic Homicide Reviews for mental health-related homicides, as suggested in the McCallion review? If so, what conclusions were reached?

As highlighted earlier, HSSIB works across multiple areas of care delivery i.e. independent and NHS care provision. This requires engaging with a multitude of organisations that deliver, direct or influence care provision; this includes NHS England, CQC, Ministry of Justice and Department of Health and Social Care (DHSC). During our investigations we use Subject Matter Advisors (experts within areas of care), and this allows HSSIB to have balanced perspective of the issues the system is subject to. To support this approach, HSSIB use a wide variety of methodologies during its investigations including (but not limited to):

• Systems Engineering Initiative for Patient Safety - SEIPS
• Sequential Time Event Plotting – STEP
• Functional Resonance Analysis Methodology – FRAM
• Accimap
• Australian Transport Safety Bureau – ATSB method
• CARE model
• Hierarchical task analysis

6) Triangulation of Findings

HSSIB uses a multitude of analysis methodologies – this allows evidence to be correlated and compared. Investigation reports are shared on consultation with key stakeholders to provide additional rigour and check and challenge prior to any final investigation report being published.

Whilst HSSIB do not have a mandate to track implementation of recommendations made within safety investigation reports they are developing a process for monitoring and assessing the impact the recommendations are having on the healthcare system.

Recognising that many organisations publish reports with accompanying recommendations the DHSC acknowledged the value in creating the ‘Recommendations to Impact Collaborative Group.’ This group draws together arm’s length bodies involved in care provision. The purpose of the group is to look at ways in which to increase collaboration and efficiencies in how safety recommendations made to the healthcare system are developed, made, and implemented. More information on this group can be found at Recommendations but no action.

7) Recurring Themes Reports

Does HSSIB produce reports on recurring themes similar to those produced by HQIP/ the National Confidential Enquiry into Patient Outcome and Death (NCEPOD)? If not, does HSSIB intend to establish such a facility for providers to carry out self-assessments regarding how they are addressing recurring themes in the various investigations carried out by HSSIB?

HSSIB can produce a safety report on the topic it decides (subject to meeting the investigation criteria – more details can be found on the what we investigate page.

The recent series of safety investigation reports into mental health inpatient care were not subject to HSSIB investigation criteria, these were Secretary of State directed in accordance with HCA Part 4 Sect 111.

8) Metrics and Key Performance Indicators

a) What metrics or key performance indicators does HSSIB use to measure the impact and outcomes of their investigation processes, especially regarding learning, service improvement, and policy development in mental health services?

HSSIB does not currently have key performance indicators that are based on the impact or outcomes of learning or service improvement. Our key performance indicators are currently under discussion with the DHSC and would apply across all investigative work HSSIB conducts, they would not be focussed solely on mental health care investigations.

9) Family and Carer Involvement

Involving patients, families and carers is vital to every investigation HSSIB undertakes. Our aim is to involve patients and families affected by safety incidents in our investigations in a manner that is agreeable to those affected. Our most common approach is to speak to / interview patients, family members or carers; this could take place on a ward, in the person’s home or another agreeable location. We can also take alternative approaches for example during our recent investigation into Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services – during this investigation, HSSIB utilised a series of focus groups which patients, families or carers could attend.

We also ensure that patients, families, and carers are supported throughout the investigation process. More information on how we involve patients, families and carers can be found on the information for patients and families page.

10) What information does HSSIB hold on Emerging Trends and Systemic Vulnerability Analysis (Trend Analysis and Systemic Vulnerability Mapping in mental health related investigations) for the period 2013 to 2024? 

HSSIB does not publish any data on Emerging Trends and Systemic Vulnerability Analysis specific to mental health or other care areas. Evidence from our investigations is subject to HCA 2022 Part 4 Sect 122 – Prohibition on disclosure of HSSIB material. To publish data on emerging trends, the data would have to meet the exceptions as defined in Health and Care Act Part 4 Sect 123.