HSSIB’s latest investigation has found that not involving temporary NHS staff in serious incident investigations may ‘undermine’ its ability to improve patient safety.
HSSIB’s report emphasises that Trust level investigations are an important way of identifying learning to improve systems and safety. However, during an analysis of 30 serious incident investigation reports they found 18 cases (May 2022 – May 2023) where locum, bank or agency staff involved in an incident were then not involved in the subsequent investigation.
HSSIB highlights that the main risk, if temporary staff are not included, is the loss of vital information and learning, raising the possibility of a reoccurrence of patient harm. This is also evidenced by the Parliamentary and Health Service Ombudsman (PHSO). They recognised that relevant staff not being interviewed or engaged in an investigation affects the thoroughness of the investigation and can contribute to additional or ‘compounded’ harm for the patient or family involved.
After the initial analysis, HSSIB carried out site visits and talked to NHS Trusts, providers of bank staff, agencies that supply staff, permanent NHS staff, bank and agency staff, and a range of national stakeholders. They examined the full local investigation process looking at incident reporting, involvement in the investigation (how temporary staff are contacted), the investigation process including evidence collection, sharing learning and support for temporary staff.
Some specific examples of challenges during the process included:
- Access to systems - electronic systems for reporting incidents in trusts were not always available to temporary staff. This included when the temporary staff member was in charge of a shift. Some Trusts told HSSIB that this has led to workarounds and adaptations, for example, they will ask a permanent member of staff to report for them.
- Differences between types of temporary staff - the ease with which a temporary staff member could be engaged in an investigation varied. This variability was influenced by whether they were agency or bank staff. For example, bank staff were described as often easier to contact and engage with as they were employed either directly by the trust or by a provider that was sub-contracted to manage temporary staff.
- Sharing learning - two trusts told the investigation that they routinely fed back the findings from relevant investigations to temporary staff via agencies. Other trusts did not have such processes in place and one trust told the investigation that such feedback would only likely happen if the temporary staff member “happened to be at the team meeting where it was shared”.
Overall findings included:
- Limited engagement of temporary staff in patient safety investigations may limit the potential for learning and undermine an investigation’s ability to influence future safety improvements.
- Patient safety investigations are being concluded without vital information because of observed and perceived barriers to engaging with temporary staff.
- Temporary staff are not always able to report patient safety incidents, and this impacts on the development of an open reporting culture and the ability to learn from patient safety incidents.
- The extent to which patient safety investigation findings are fed back to temporary staff varies, limiting the ability for all of those involved to learn.
- Support is not always provided for temporary staff following a patient safety incident; this can have an impact on staff members’ welfare and on patient safety.
- NHS England’s approved framework agreements for agency staff do not specifically refer to patient safety, or to support for staff following patient safety incidents.
The report concludes with two safety recommendations to NHS England aimed at increasing the engagement of and support for temporary staff. HSSIB have also included prompts in the report for healthcare providers to help them consider how they involve temporary staff in patient safety investigations:
Matthew Mansbridge, Senior Safety Investigator said, “Our investigation provides robust evidence that in some cases temporary staff are never involved in a serious incident investigation, even when they may have crucial insight to share. We recognise this can happen, even when the provider and staff member have done everything they can. However, we also saw examples of where the barrier to including temporary staff was perceived rather than actual, and there was no strong rationale for why they were not involved.
“Consistency is needed at both a national and local level in relation to the involvement of temporary staff. Patients and their families should be assured that any investigation undertaken into what can be life-changing incidents are as complete as possible, capturing the accounts of all staff involved. This creates the best environment for learning, system changes and minimising the chance it will happen again.
"The investigation report contains critical insight and learning for all – from those working on the frontlines of the NHS to national organisations. Sharing our findings and prompts at a local level, and implementing safety recommendations will help to support inclusion, reducing the likelihood that temporary staff become a lost voice during serious incidents in healthcare.”
Responding to the report, RCN Director for England Patricia Marquis, said: “When things go wrong in the NHS it is vital they are investigated so lessons can be learnt, and steps taken to prevent them from happening again. All nursing staff, no matter their contractual status or role, should have an opportunity to input into investigations.
“Delivering safe and effective patient care is being hindered by a chronic workforce crisis which sees tens of thousands of nursing posts lay empty across England’s NHS. As a result, providers over-rely on agency and temporary staff, harming continuity of care and disrupting the reporting of incidents which more effectively takes place with permanent staff.
“Billions of pounds is spent on temporary and agency staff, but the failure to involve them when things go wrong comes at the cost of patient care. They must not be excluded from any investigations. Failure to do this could lead to possible systemic issues going unrecognised.
“High-quality services require a stable workforce with higher numbers of permanent staff delivering continuous care. But this can only be built by improving the pay and working conditions of those who work in the NHS.”
For further information, visit: https://www.hssib.org.uk/patient-safety-investigations/workforce-and-patient-safety/
