Healthcare Safety Investigation Branch

The Healthcare Safety Investigation Branch is a part of NHS England, established in April 2017, to operate independently of other regulatory agencies. [1] It is intended to produce rigorous, non-punitive, and systematic investigations and to develop system-wide recommendations for learning and improvement and to be separate from systems that seek to allocate blame, liability, or punishment.

In June 2019 it employed about 200 full-time equivalent staff and its budget had increased from £3.8 million in 2017 to almost £20 million. There were criticisms of the management of the organisation under chief investigator Keith Conradi.[2]

England was the first country to adopt such a system. Norway is launching a similar organisation in 2019 called the National Investigation Board for the Health and Care Services.[3]

From 2018 it has been responsible for the investigation of maternity cases which involve intrapartum stillbirth, early neonatal deaths or severe brain injury. A maternity caseload of around 400 is expected, with about 3 new referrals daily.[4]

It has already started producing reports on never events.[5]

In February 2019 it produced a report into mistakes involving piped air being mistakenly supplied rather than piped oxygen and said that cost pressures could make it difficult for trusts to respond to safety alerts the financial costs of replacing equipment. Private finance initiative contracts increased those costs.[6]

In January 2020 it called for systematic monitoring of eye health follow-up appointments after large numbers of patients had their sight put at risk from delayed follow-ups.[7]