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The Report
Volume III
Part Two
Chapter 43

Chapter 43. The Health Services Safety Investigations Body

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Chapter 42
Care Quality Commission
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Chapter 44
Memorandum of Understanding

Contents

Background and context

  1. The Health Services Safety Investigations Body (HSSIB), established under the Health and Care Act 2022,1 investigate patient safety issues across health services in England.2 Their investigations are national in scope and are distinct from regulatory, disciplinary and judicial processes. HSSIB are not concerned with the attribution of blame to individuals or organisations and do not investigate civil liability, criminal conduct or professional fitness to practise, which remain matters for civil courts, the police, prosecuting authorities and professional regulators.
  2. The role of HSSIB is to carry out independent investigations that identify risks to patients and facilitate the improvement of systems and safety practices in the provision of healthcare services in England. HSSIB focus their investigations on patient safety issues that occur in multiple places across the country, and on issues where HSSIB consider they can add value and address inequalities.
  3. HSSIB prioritise learning lessons about safety over individual accountability. To achieve this, they have created a safe space where staff can speak openly without fear of disciplinary action, professional referral, civil litigation or criminal investigation. Information, including witness accounts, staff interviews and evidence gathered or held by HSSIB for the purpose of safety investigations, is considered under statute to be “protected material”, and must not be disclosed to any person,3 save in the case of limited exceptions, as set out in Schedule 14 of the Health and Care Act 2022, or if ordered by the High Court.4 Statutory powers cannot compel the disclosure of protected material, nor can such material be voluntarily shared with regulators, employers, the police, families, courts or litigants.5

Dr Benneyworth

  1. Dr Benneyworth, the interim Chief Executive of HSSIB, gave evidence to the Inquiry. She explained:
    “The HSSIB investigations are protected, the material that comes in to the organisation as part of the course of those investigations [is] protected by law. What that means is we don’t disclose any of that information into any kind of legal proceeding, we don’t talk about names of individual organisations, individual Trusts and we don’t name individuals that have contributed to our investigations.”6
  2. Dr Benneyworth went on to explain the importance of the legislation in enabling people to speak freely during investigations without fear of recrimination or being blamed.7 She noted in her evidence:
    “Investigations have shown [you] healthcare staff greatly value the opportunity to speak with an independent and professional investigation team. Speaking openly about what happened after a patient safety event is easier when staff know the purpose of the conversation is to identify the systemic risks that made delivering healthcare safely more difficult rather than to pinpoint individuals for blame.”8
  3. Significantly, however, disclosure would be permitted under Schedule 14 of the Health and Care Act 2022 where the chief investigator “reasonably believes that the disclosure of the material is necessary to address a serious and continuing risk to the safety of any patient or to the public”, and “that the person [to whom the material is disclosed] is in a position to address the risk”.9
  4. Dr Benneyworth explained that the exemptions in the legislation mean that, if a disclosure is made concerning negligence, criminal behaviour or any immediate risk to patients, HSSIB will flag these internally in the provider organisation.10 Further, if HSSIB do not consider that the organisation is taking action, the concern can be raised with regulators and the police if necessary.*
  5. Dr Benneyworth was asked about the situation where there were suspicions of deliberate harm. She stated that these issues would be escalated and not ignored, noting also that all the HSSIB team were trained in safeguarding.11 She said:
    “[I]f my team when they are out investigating areas have concerns about negligence, have concerns about any criminality or do have concerns that there is a very significant risk that the provider is not addressing then we will escalate those and we have the exceptions within our legislation to be able to do that.”12
  6. HSSIB are modelled on accident investigation branches in transport, which gather evidence solely for safety investigations and have strong statutory prohibitions on disclosure in order to promote candour, learning and non-blame. Further, the team of HSSIB investigators bring experience from safety-critical industries and other professions, including healthcare, military, aviation and law.13
  7. However, HSSIB’s Annual Report and Accounts 2024/25, in its foreword by the Chair, Professor Baker, acknowledges that healthcare still lags behind other industries:
    “Other safety critical industries have paved the way and provide principles and learning that should be adopted and adapted for healthcare … [W]e still are not close to other industries in relation to how they manage, plan, and mitigate safety risks. Crucially, they have built a culture around safety that provides a clear framework for accountability without attributing blame.
    …
    Through our work and analysis of safety management, we have found that effective safety investigation bodies in other industries issue a small number of high-impact recommendations, which are then implemented and embedded by national regulatory bodies. This is the standard we must achieve in healthcare.”14
  8. In health, the complexity of the NHS regulatory and governance landscape, the competing organisational priorities and the cumulative volume of safety recommendations issued across the system risk diluting the impact of HSSIB’s reports and their training role.15
  9. Dr Benneyworth spoke of the need to empower local systems to deliver good care, noting this might require the “rationalisation of organisations”. However, she considered the immediate priority was to collaborate and consider “how we coordinate things much more formally across the system”.16
  10. In addition to their investigatory role, HSSIB also have an education team which deliver a training programme to help healthcare staff improve patient safety in their organisations. The aim is to support a professional approach to healthcare safety investigations and to ensure learning from patient safety incidents.17
  11. Dr Benneyworth spoke about the need for education and training of those working within hospitals faced with conducting an investigation. She considered that managers need to listen to staff when they speak up, noting the need for a no-blame philosophy, where people feel encouraged to talk openly and are not bullied or subjected to poor behaviour as a result.18 In her evidence, she said:
    “So often we hear from patients and families involved in investigations that they are not involved well in investigations.
    We often hear that staff are often made to feel blamed when local investigations happen and often that the local investigations don’t lead to the changes and the improvements that are needed on the ground. So we think it’s very important that we upskill investigators that are undertaking these very complex investigations locally.”

She went on to say: “We really need to understand the system wide factors as to why things go wrong. Often it is not one individual — one individual person or one individual problem that leads to things going wrong.”19

  1. HSSIB training courses, predominantly delivered online,20 are primarily aimed at staff who are involved in safety investigations. They are delivered by an education team that are drawn from multiple disciplines, including academia, healthcare, nuclear, occupational psychology and the police.21 Dr Benneyworth noted in her evidence that “investigation is one of those skills that is often undervalued … [I]t needs very specialist [skills;] it doesn’t need necessarily clinical skills, it needs the subject matter expertise, it needs specialist investigation skills and I think that’s quite under-recognised really in the system in terms of the skills need.”22 This is an important point. It arises in employment situations, where untrained managers are expected to investigate complaints about a staff member from other members of staff. It arose at the Countess when Mr Harvey conducted his investigation in July 2016 with neither specialist investigation skills nor relevant clinical skills (see Chapter 15). Dr Green’s inadequate conduct of the grievance investigation (see Chapter 22) was the result of inexperience and lack of training.
  2. Dr Benneyworth also acknowledged the financial and operational pressures on middle and senior managers, and the fact that this can lead to those who raise concerns facing poor behaviours. She explained that, often, “there isn’t an easy fix [to the safety concern] and so for a very busy person working in a challenging … environment I suspect when someone raises concerns and they don’t know how to fix it that can cause tensions”.23 Along with financial and operational pressures, reputational issues loom large, as they did at the Countess, and divert the senior managers from their primary task of keeping patients safe.
  3. Dr Benneyworth noted that HSSIB have observed that, when people raise concerns and are not listened to, frustrations grow. This can lead to escalating tensions within relationships. Further, if middle managers do not have an escalation route, they can feel helpless and powerless in terms of what they can do. To combat this, Dr Benneyworth considered it important that the right culture is set at board level. This includes listening to people when they speak up and taking appropriate action.24 The importance of listening is underestimated in many settings, including healthcare. Where a whistleblower raises a concern, it should be listened to and acted upon. As I have mentioned elsewhere in the Report, this is not always a given in hospital settings.
  4. Dr Benneyworth outlined that HSSIB training includes training for senior managers and board members:
    “[W]e actually run a programme that is becoming increasingly popular, which is called a strategic decision managers — makers programme and that’s a two hour programme that we run with boards, with senior leadership teams face to face and it really gives, gives the kind of people in those boards and those senior leadership teams the understanding as to how to support people doing these investigations, understanding about how you take a systems-wide approach so how do you move away from looking at what an individual has done to what actually the environments, the processes the systems that are going to help your teams deliver better care.”25
  5. Dr Benneyworth also spoke of the benefits of training people in healthcare organisations, so that patients and their families feel that the investigation is done properly and that they are at the centre of the investigation. Further, training can assist investigators in understanding how to untangle the complexity of the system, look at system-wide factors as to why things have gone wrong, and make changes on the ground to prevent the cycle of harm happening again.26
  6. Dr Benneyworth described circumstances where, after an incident, healthcare professionals are secondary victims. She explained this is because healthcare professionals, particularly those who raise concerns, are blamed and made to feel responsible for what has happened, which can exacerbate stress.27
  7. Dr Benneyworth also emphasised that there is a financial benefit to improving safety, and that it is imperative that safety is not an afterthought. She explained that dismissing safety concerns is counterproductive, because “between 12 and 15% of an organisation’s spend” is “on safety failure”.28 If safety concerns are addressed, this in turn helps alleviate some of the financial and operational pressures faced by senior leaders and boards.29
  8. Dr Benneyworth was an impressive witness. It is clear that HSSIB have contributed to the identification of cross-cutting patient safety risks that are deemed unlikely to be fully addressed through local provider-led investigations alone. Their reports have resulted in national recommendations directed at regulators, commissioners and policy-makers.30
  9. However, HSSIB have no enforcement powers and rely on other organisations to respond to, and implement, their recommendations. This creates the risk of an ‘implementation gap’ between learning and tangible improvement.31 Further, HSSIB are a small organisation with a limited budget. Dr Benneyworth was candid in her evidence that HSSIB are “an incredibly small team so our resources are limited”.32 At the time of her evidence to the Inquiry (January 2025), there were 44 members of staff working remotely around the country.33

Continuation and development of HSSIB

  1. The strongest argument for the maintenance of a training and investigatory body such as HSSIB is that it encourages candour and honesty. Clinicians are more willing to speak openly, and instances of withholding information or providing sanitised or legally defensive narratives are reduced. Investigations focus on human factors, organisational culture and system design, rather than individual blame. The aim is that this approach leads to better safety recommendations and identification of latent risks. The hope is also that a no-blame approach to investigations leads to less defensive behaviour and improves systemic learning, because witnesses feel protected. In the long term, the cultural benefit would be clinicians who are less likely to practise defensively, with fewer distortions of care motivated by fear of litigation.
  2. The experiences at the Countess demonstrated that, despite Freedom to Speak Up initiatives, staff did not feel able to raise concerns. Dr Brearey expressed regret that he did not spell out his concerns clearly in the Thematic Review. Dr Jayaram referred to the need for courage to speak out, and Dr Isaac feared repercussions and so she did not send a letter raising her concerns. Ms Lawrence felt (and was) reprimanded for voicing her worries about the deaths on the neonatal unit and a possible association with Letby.
  3. The Inquiry also heard evidence that doctors feared disciplinary action or professional referral. The fear was not illusory. Dr Brearey and Dr Jayaram both received letters that made reference to referral to the GMC and both were criticised following the grievance procedure, to the extent they were required to apologise to Letby.
  4. The experiences at the Countess suggest that there is a place for HSSIB. It is true that the issue at the Countess was one of concern about a particular nurse on a particular unit. This is not the sort of systemic issue that HSSIB would investigate. However, the Inquiry into the events at the Countess has revealed issues that were almost certainly more widespread:
    1. the misunderstanding of SUDIC guidance, with regard to a baby that dies suddenly and unexpectedly in hospital
    2. the failure to train staff that concerns about a member of staff harming a child raises safeguarding issues
    3. the failure to follow safeguarding procedures
    4. the continued barriers – despite Freedom to Speak Up initiatives – to healthcare staff speaking up
    5. the failure of senior managers to listen to genuine concerns
    6. the apparent inability of the senior executives to handle a serious complaint that raised the possibility of deliberate harm, and to know when referral to the police was appropriate.
  5. HSSIB have the advantage of conducting national investigations and can thus address issues that are widespread. An investigation which hears evidence from clinicians, given without fear of reprisal, could lead to “a small number of high-impact recommendations, which are then implemented and embedded by national regulatory bodies”. This is what HSSIB say, in their annual report, is the hallmark of “effective safety investigation bodies in other industries”.34
  6. The experiences at the Countess exposed the need to train those who investigate complaints or concerns within hospitals. At almost every stage of the investigation, from the first concerns being raised about Letby to the belated referral to the police, and at all levels, from the ward sister and the Risk and Patient Safety Lead to the executives, there were errors in the approach to investigation. There was a failure to recognise, still less consider at an early stage, the fact that staff rotas may be a potential factor in the increased mortality. There was a failure to prioritise the safety of babies and to remove Letby pending investigation, in accordance with fundamental safeguarding principles. Even once Letby was belatedly moved off the neonatal unit, the executives became distracted by the grievance process and failed to recognise that the concerns about Letby were matters that required police investigation.
  7. Had staff at the Countess undergone training by HSSIB, some of these errors may have been avoided. Looking to the future, training must ensure that such failings are not repeated.
  8. It is true that HSSIB exist in an already overcrowded and complex regulatory landscape, and that the concept of ‘protected disclosure’ means material obtained in the course of an investigation will generally be legally inaccessible to families, regulators and courts. Some patients and bereaved families may well object to the absence of individual accountability within the process and there is the possibility of parallel investigations and duplication of evidence-gathering. Healthcare, unlike transport incidents which employ ‘no-blame’ investigations, concerns the ongoing care of a patient in an environment where there is a strong expectation of individual accountability.
  9. However, the events at the Countess demonstrate that failings in handling concerns raised by staff are likely to exist beyond an individual institution. This calls for an investigatory organisation that can consider national and systemic problems. The learning from other industries, that a no-blame approach changes the culture and improves safety, is compelling but, as I have said earlier, it has not been successful in changing the culture in the NHS. Above all, the evidence from the events at the Countess suggests that internal investigations are failing and the need for training of investigators is necessary.
  10. It is undoubtedly the case that coordination and a rationalisation of regulatory organisations is necessary. HSSIB’s greatest test of success would be to get to a point where they were no longer needed. However, at present, HSSIB are fulfilling a needed function and require the resources and staff to carry on doing this effectively.

Footnotes

  1. * Any person who intentionally obstructs an HSSIB investigator and fails, without reasonable excuse, to comply with the notice to provide information, or provides false or misleading materials to HSSIB, may be liable, on summary conviction, to a fine. These powers have been in place since October 2023. However, they have not yet been used.

Endnotes

  1. 1 Health and Care Act 2022, Part 4 (https://www.legislation.gov.uk/ukpga/2022/31/part/4)

  2. 2 Health and Care Act 2022, section 110 (https://www.legislation.gov.uk/ukpga/2022/31/section/110)

  3. 3 Health and Care Act 2022, section 122 (https://www.legislation.gov.uk/ukpga/2022/31/section/122)

  4. 4 Health and Care Act 2022, Schedule 14, para 5(4) (https://www.legislation.gov.uk/ukpga/2022/31/schedule/14)

  5. 5 Health and Care Act 2022, sections 122 and 125 (https://www.legislation.gov.uk/ukpga/2022/31/section/122)

  6. 6 Dr Rosie Benneyworth 8 January 2025 4/16-23

  7. 7 Dr Rosie Benneyworth 8 January 2025 5/4-9

  8. 8 Dr Rosie Benneyworth 8 January 2025 19/16-23

  9. 9 Health and Care Act 2022, Schedule 14, para 4 (https://www.legislation.gov.uk/ukpga/2022/31/schedule/14)

  10. 10 Dr Rosie Benneyworth 8 January 2025 59/14-19

  11. 11 Dr Rosie Benneyworth 8 January 2025 6/19-21

  12. 12 Dr Rosie Benneyworth 8 January 2025 6/9-15

  13. 13 HSSIB, ‘Who we are’ (https://www.hssib.org.uk/about-us/who-we-are/#independent-patient-safety-investigations)

  14. 14 HSSIB, Annual Report and Accounts 2024/25, 17 July 2025, page 5 (https://hssib-ovd42x6f-media.s3.amazonaws.com/production-assets/documents/HSSIB_Annual_Report_and_Accounts_202425.pdf#page=8)

  15. 15 Dr Rosie Benneyworth 8 January 2025 39/1-5

  16. 16 Dr Rosie Benneyworth 8 January 2025 53/11-15

  17. 17 Dr Rosie Benneyworth 8 January 2025 8/23 to 11/5

  18. 18 Dr Rosie Benneyworth 8 January 2025 22/12 to 23/9

  19. 19 Dr Rosie Benneyworth 8 January 2025 9/5-20

  20. 20 Dr Rosie Benneyworth 8 January 2025 12/18-21

  21. 21 HSSIB, ‘Our team’ (https://www.hssib.org.uk/about-us/our-team/)

  22. 22 Dr Rosie Benneyworth 8 January 2025 13/12-18

  23. 23 Dr Rosie Benneyworth 8 January 2025 23/15-19

  24. 24 Dr Rosie Benneyworth 8 January 2025 27/2-7

  25. 25 Dr Rosie Benneyworth 8 January 2025 12/1-13

  26. 26 Dr Rosie Benneyworth 8 January 2025 69/8 to 70/2

  27. 27 Dr Rosie Benneyworth 8 January 2025 21/22-25

  28. 28 Dr Rosie Benneyworth 8 January 2025 28/11-12

  29. 29 Dr Rosie Benneyworth 8 January 2025 28/12-15

  30. 30 HSSIB, ‘Patient safety investigations’ (https://www.hssib.org.uk/patient-safety-investigations/?page=1)

  31. 31 Patient Safety Learning, ‘Mind the implementation gap: The persistence of avoidable harm in the NHS’, 7 April 2022 (https://www.patientsafetylearning.org/blog/mind-the-implementation-gap-the-persistence-of-avoidable-harm-in-the-nhs)

  32. 32 Dr Rosie Benneyworth 8 January 2025 13/2-3

  33. 33 Dr Rosie Benneyworth 8 January 2025 8/8

  34. 34 HSSIB, Annual Report and Accounts 2024/25, 17 July 2025, page 5 (https://hssib-ovd42x6f-media.s3.amazonaws.com/production-assets/documents/HSSIB_Annual_Report_and_Accounts_202425.pdf#page=8)

Previous
Chapter 42
Care Quality Commission
Next
Chapter 44
Memorandum of Understanding