Integrating restorative justice into patient safety investigation

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Paul Bowie, Senior Investigations Science Educator at the Health Services Safety Investigations Body (HSSIB). — Paul Bowie, Senior Investigation Science Educator.

Jo is a recognised global expert in the field of restorative practice and justice in healthcare. This is an area of growing interest in the NHS, especially as the processes for organisational and national learning from patient safety incidents evolve.

What is restorative justice?

Restorative justice brings those harmed by crime or conflict and those responsible for causing their harm into contact with each other. This enables everyone affected by a particular incident to play a part in helping to set right the hurt or injury caused, and hopefully find a positive way forward. This is part of a wider field called restorative practice.

Restorative practice can be used anywhere to prevent conflict, build relationships, and repair harm by enabling people to communicate effectively and positively. Restorative practice is increasingly being used in schools, children’s services, workplaces, hospitals, communities, and the criminal justice system.

The restorative response to when something goes seriously wrong in healthcare provides a compassionate, respectful, and caring way of responding to the problem that aims to foster healing, restoration, and learning for all people affected.

Learning from surgical mesh harm in New Zealand

During our seminar, Jo shared her experience of co-designing and evaluating New Zealand's innovative restorative response to surgical mesh harm. She did this work in 2020 as part of a group from Te Ngāpara Centre for Restorative Practice at Te Herenga Waka - Victoria University of Wellington, in partnership with the New Zealand Government’s Ministry of Health and the consumer advocacy group Mesh Down Under.

Surgical mesh is a medical device used to repair weakened structures, for example hernia repair and urogynaecological surgery. While many people do not experience adverse effects, some experience complications straight after surgery, and others years after. Complications range from mild to debilitating and can impact someone’s quality of life.

A restorative approach to surgical mesh harm was delivered in three phases:

Listening and understanding
Planning and acting
Reporting and evaluating

During the listening and understanding phase, over 600 women and men shared their experiences, with additional stories provided by health professionals. This demonstrates the massive extent of harm and injury after surgical mesh procedures.

Practical examples for patient safety investigations

Drawing from her experience, Jo outlined some practical insights into implementation of a restorative response to patient safety incidents and related learning and healing.

Examples of Restorative Principles and Practical Examples
Principle	Practice examples
Process is voluntary	Participants are prepared for a facilitated meeting. Consent to proceed is agreed by all parties (including the facilitator). Confidentiality parameters are agreed. Independent facilitators are used if requested.
Active participation	Substantive, procedural, and psychological needs of all parties are clarified during preparation, e.g. who needs to be involved? How would people like to tell their story and to whom?
Respectful dialogue	Ground rules established during preparation and start of meeting. Facilitators minimise interruption and ensure conversational turn taking. Facilitators uphold the ground rules by interjecting when required to reframe, redirect, or remind participants of their commitments. If required, facilitators supported private conversations to clarify and repair and perceived hurtful comments.
Safe environment	Confidentiality rules agreed at the outset, e.g. what will be shared and with whom. Access to emotional support before, during and immediately after a meeting. Practical/comfort needs are attended to. Physical safety needs addressed. Organisational policies support a just response that does not blame an individual or team for systemic failures. Independent facilitators are used in cases of sever or intractable conflict.
Skilled facilitation	Trained practitioners guide the co-design, preparation, restorative process, and debriefing. Experienced or external practitioners are used in cases of severe harm or when requested by the people involved.
Responsibility taking	Responsible parties directly hear about the harm experience to identify individual and shared responsibilities.
Collaborative problem solving	Restorative practices (conversations, facilitated meetings and Circles) have a democratic structure that is psychologically safe and supports shared decision making. Responsible parties asked to listen and reflect key themes.
Collaborative decision making	Potential actions are collectively agreed.
Outcomes documented and shared	Specific actions for repair and prevention are documented in a shared agreement. The agreement usually documents agreed timeframes, any monitoring requirements, and how parties will know that actions have been delivered.
Ongoing relational response	Ongoing communication, roles, and responsibilities are agreed.

What are we doing at HSIB around restorative justice?

At HSIB, as well as introducing the concept of restorative justice as part of our evolving educational offerings, we have begun to explore in what ways key principles can be integrated within the investigations we undertake.

However, there is much work to be done in terms of raising awareness of this field of practice, testing and evaluating feasible approaches in frontline NHS practice, and influencing policy in this area.

Find out more about our investigation education programme