Health and Care Act 2022

Investigations

110 Investigation of incidents with safety implications

(1) The HSSIB has the function of investigating incidents that—

(a) occur in England during the provision of health care services, and

(b) have or may have implications for the safety of patients.

(2) The purpose of the investigations is to—

(a) identify risks to the safety of patients, and

(b) address those risks by facilitating the improvement of systems and practices in the provision of NHS services or other health care services in England.

(3) In particular, where an investigation relates to an incident that did not occur during the provision of NHS services, the HSSIB must consider whether, in relation to any risks identified, the systems and practices in the provision of NHS services could be improved.

(4) The purpose of the investigations does not include assessing or determining—

(a) blame,

(b) civil or criminal liability, or

(c) whether action needs to be taken in respect of an individual by a regulatory body.

(5) In this Part, an incident within subsection (1) is called a “qualifying incident”.

111 Deciding which incidents to investigate

(1) The HSSIB’s function under section 110 includes determining which qualifying incidents it will investigate, subject to subsection (2).

(2) The Secretary of State may direct the HSSIB to carry out an investigation of—

(a) a particular qualifying incident that has occurred, or

(b) qualifying incidents that have occurred and are of a particular description.

(3) A direction under subsection (2) may specify the date by which the HSSIB must publish its final report (see section 113).

(4) A direction under subsection (2)—

(a) must be in writing;

(b) may be varied or revoked by subsequent directions;

(c) may provide for a person to exercise a discretion in dealing with any matter.

(5) Once the HSSIB has begun an investigation into a qualifying incident, it must, in such manner as it thinks appropriate, publish a statement which—

(a) reports that it has begun the investigation,

(b) contains a brief description of the incident, and

(c) sets out, in general terms, the issues that the HSSIB expects to consider in the investigation.

(6) The HSSIB may give advance notice of a statement under subsection (5) to any person the HSSIB considers may be affected by the investigation.

(7) Where the HSSIB discontinues an investigation, it must, in such manner as it thinks appropriate, publish a statement which—

(a) reports that it has discontinued the investigation, and

(b) gives its reasons for doing so.

(8) Where the HSSIB determines not to investigate a qualifying incident, it may give notice of its determination to any person the HSSIB considers to have an interest in the determination.

(9) Notice under subsection (8) may include—

(a) a brief description of the incident, and

(b) the HSSIB’s reasons for not investigating it.

112 Criteria, principles and processes

(1) The HSSIB must determine and publish—

(a) the criteria it will use in determining which incidents it investigates,

(b) the principles which are to govern investigations,

(c) the processes to be followed in carrying out investigations, and

(d) the processes for ensuring that, so far as reasonable and practicable, patients and their families are involved in investigations.

(2) The processes determined under subsection (1)(c) must include—

(a) the procedures and methods to be used in investigations (including in the interviewing of persons), and

(b) the time periods within which the HSSIB aims to complete investigations.

(3) Different processes under subsection (1)(c) or (d) may be determined for different descriptions of investigation.

(4) Anything published under subsection (1)(d) must be—

(a) easily accessible to patients and their families, and

(b) capable of being easily understood by them.

(5) The HSSIB must review the criteria, principles and processes—

(a) within the period of three years beginning with their publication under subsection (1), and

(b) subsequently within each period of five years beginning with the completion of the previous review.

(6) If the HSSIB revises the criteria, principles and processes it must publish them as revised.

(7) In determining or revising the criteria, principles and processes the HSSIB must consult—

(a) the Secretary of State, and

(b) any other persons the HSSIB considers appropriate.