“Darling, I’m sorry but the undertaker wants to know if we want a burial or the crematorium…”
“I’m just filling in a HSIB Patient Safety Awareness form.”
“A what? What’s HSIB?”
“The Health Safety Investigation Branch… Some government thing.”
“We need to make a decision. Apparently the cemeteries are pretty full around here.”
“Sorry, I’m stuck on this question: Why do you think HSIB should investigate your incident?”
“Christalmighty. He died for fucks sake.”
HSIB was launched this week. Led by Keith Conradi, an air safety expert and pilot, with over 40 years of experience. The new branch is allegedly independent despite being called a branch, based within NHS Improvement and funded by the Department of Health.
I’m sure Conradi is an ace guy. I’m sure he knows his air safety stuff. Patient deaths and bereaved families? Not so sure. The ‘its’ and ”relatives of incidents’ on the HSIB website suggest not.
The gig is that HSIB will investigate 30 deaths a year using a Human Factors approach. There is a set of criteria for selecting these deaths; outcome impact, systemic risk and learning potential. Your daughter, father, brother, sister, mother has become a learning tool and the bigger the potential learning from their death, the more chance they have of making the cut.
If you understand the various hoops on the website and get through them, you eventually (after two pages with an identical ‘get started’ button) reach a link to the Patient Safety Awareness Form. The potential gold ticket. This kicks off by asking:
When did the problem you want to share with us happen?
I kid you not. The problem... The incident. Relatives of the incident. Human Factors bods take the non-pursuit of blame to a level that doesn’t translate well into health care. Reducing death to ‘a problem’ will probably send most bereaved families who have got this far into further pieces. If they limp through to the final page of the form, they are expected to produce a coherent justification as to why the death of their loved one reaches the criteria for investigation.
I don’t know. There is something different about approaches to safety in the airline industry and safety in the NHS. Dragging Human Factors from the former to the latter (without some reflection, understanding, empathy and commitment to adapt the process to the very different context) clearly necessitates an erasure of the human and focus on nothing but systems. But health care is necessarily messy, interactive and drenched in human. It involves patients who die in a many different ways, at different times. In the airline industry I assume (please tell me if I’m wrong) that a plane crash generates an instant grouping of deceased passengers, and their relatives, who have some shared experience of this catastrophic event or happening.
On twitter tonight I was introduced to the concept of “second harm”. This is:
Blimey. Second harm. This is so important (and makes me want to scrowl given the battering we, and so many other families, have experienced because our beyond loved children, parents, sisters or brothers died in the ‘care’ of the NHS).
The information on the new HSIB site is offensively phrased, not accessible and the process of ‘referring incidents’ is exclusionary; it assumes particular levels of understanding, articulation and engagement. And, as importantly, ignores grief and humanity.
It has, in short, considerable potential generate more second harm. Classy stuff.
Oh Sara, you are so right. You usually are. Airlines are not health care, human factors approach has much to commend it, but not like this. Good grief, how do they do it, and continue to do it. With both sympathy and admiration for your campaign, as ever, Jan
Perhaps Keith Conradi and the HSIB would like to investigate Sloven’s record on epilepsy, now summarised at https://999crash.wordpress.com/2017/04/29/epilepsy-rage/
It would appear that the HSIB is just another locked gate bereaved families will have to pick before the truth is skewed and written off.
its completely rotten, right through to its rotten core. Well summarised, articulate and rage inducing. Thank you Sara.
Interesting to have descriptors like second harm as I think it’s a useful term, but the systems just don’t bring an end to harm. That’s the shock.
I’d go on to say harm just continues (into third and maybe fourth harm..)
When or how is this stupidity supposed to stop? It’s a drain on public finances as well as families, for others’ gain.
Sara just read the news on the BBC..
… I had not realised that it had been a year since HSIB started?
So what great shakes has been resolved and learned from?
After witnessing 15 years of public money covering up petty mistakes in 2004; I get SO irritated by these patient safety agencies. The NHS is swamped by health watch and healthcare reviewers – but we’re still here, waiting for an explanation or a factually correct resolutions.