NHS JOINS WITH POLICE & HSE TO IMPROVE INVESTIGTIONS

20 Feb 2006 11:45 AM

Better support and information for patients and relatives, improved co-ordination between services and improved learning from errors

Chief Medical Officer Sir Liam Donaldson, John Broughton, Assistant Chief Constable, Essex Police and Sandra Caldwell, Director of Field Operations at the HSE, today launched a Memorandum of Understanding (MoU) to help ensure that investigations into serious patient safety incidents are conducted in a consistent and well-coordinated manner that leads to effective learning.

The MoU was developed by the Department of Health, Association of Chief Police Officers (ACPO) and the Health and Safety Executive (HSE). The protocol forms part of the guidance promised to the NHS by the Chief Medical Officer in his report Building a Safer NHS for Patients (2001).

In developing the protocol, the three signatory bodies have consulted widely, including publicly, and with a variety of organisations ranging from professional regulatory bodies, NHS staff, police officers, HSE inspectors and others who have practical experience of these matters. All have offered strong support for the protocol.

The protocol will take effect in circumstances of unexpected death or serious untoward harm, involving NHS patients being treated in either NHS or independent sector hospitals, requiring investigation by the police, HSE or the police and the HSE jointly. This will normally be the case if an incident has arisen from or involves criminal intent, recklessness and/or gross negligence or, in the context of health & safety, involves a work-related death or serious injury. By definition, these incidents will be serious and may have significant public safety implications.

Included among the protocol's aims is a commitment to ensure:

- better and more coordinated liaison with patients and/or relatives when investigations take place

- wider learning for staff across the NHS from these incidents

- better learning from more effective investigations when necessary

- reduced disruption to services when investigations do take place

- better safeguards for patients and public

- improved risk-awareness in the NHS

- better treatment as the result of professionals feeling able to be open rather than defensive when errors do occur.

The Memorandum proposes that such incidents be co-ordinated by an Incident Co-ordination Group (ICG) involving the NHS, the police and the HSE. The purpose of the ICG is to provide strategic oversight of a patient safety incident. It is a forum for communicating, exchanging information and co-ordinating multiple investigations. The ICG will provide strategic oversight but will not direct the investigations of the police or HSE. Practical matters that the Incident Coordination will discuss include: public safety concerns, safety of NHS systems, police and/or HSE investigations, the need to inform professional regulatory bodies, securing & preserving evidence, sharing information and the needs of & support to patients, relatives and NHS staff.

Chief Medical Officer, Sir Liam Donaldson, said:

"The vast majority of NHS patients receive safe and effective care, but we have to recognise that in our modern, increasingly complex health service, mistakes do happen. By consulting early on what sort of investigation is necessary, who is to take the lead and how information is shared we can improve learning by conducting more effective investigations and reduce disruption in the day-to-day running of the NHS. It is important to recognise that the NHS is developing a learning culture where staff are encouraged to report and learn from errors rather than hide them. In this way, future similar errors can be avoided.

"This unique document will mean that patients and relatives are fully supported and kept up-to-date during very stressful situations while investigations are ongoing, and the staff in each of the three services will be able to work better together in safeguarding patient safety."

John Broughton, ACPO lead on Victims and Assistant Chief Constable of Essex Police, said:

"On behalf of ACPO I am delighted to contribute to the national launch of the MOU. The finished document is the result of considerable work and commitment from a wide range of individuals. I consider it will be a significant and important document that will enhance patient and public safety. During my chairmanship of the development group I have been struck by the spirit of partnership and cooperation that has driven the work. The challenge for those involved to share experiences and understand other agencies requirements has been challenging at times. However, overall what has been produced is for me the manifestation of what can be achieved when we all work together. The willingness to put public and patient safety at the very top of our agenda in every consideration we have made has meant we have delivered a thorough and practical process that will ultimately improve the service to those who are affected by these types of incidents.

"It has taken considerable effort to reach this point and throughout that time the team have never lost sight of the importance of enhancing the service the public receive during very distressing times and situations. The MOU acknowledges that organisations such as the police service, the health service and the Health and Safety Executive are always willing to learn lessons from these types of incidents and search for ways to forge forward and improve. "I am personally grateful for the help and support provided by all concerned in developing this MOU. I have been impressed by their openness and willingness to reach real and sustainable outcomes

Sandra Caldwell, Director of Field operations, Health & Safety Executive, said:

"HSE is really pleased to have been able to work with DH and ACPO on this important project. We welcome this agreement on best practice in liaison between the health service, the police and HSE over incidents involving unexpected death or serious untoward harm in the NHS. In particular we believe the MoU will help the different organisations work effectively together during these sensitive investigations."

Notes For Editors

1. The MOU can be found at:

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4129918&chk=P5hkFZ

- The Association of Chief Police Officers (ACPO) is an independent, professionally led strategic body. In the public interest and, in equal and active partnership with Government and the Association of Police Authorities, ACPO leads and co-ordinates the direction and development of the police service in England, Wales and Northern Ireland. In times of national need ACPO, on behalf of all chief officers, coordinates the strategic policing response.

- ACPO's 312 members are police officers of Assistant Chief Constable rank (Commanders in the Metropolitan Police and City of London Police) and above, and senior police staff managers, in the 44 forces in England, Wales and Northern Ireland, plus national agencies such as NCIS and the National Crime Squad, and other forces such as British Transport Police and States of Jersey Police.