Public Release: 

Independent safety investigation needed in the NHS


The NHS should follow the lead of aviation and other safety-critical industries and establish an independent safety investigation agency, according to a paper published today by the Journal of the Royal Society of Medicine. The authors say the NHS has no consistent approach to investigating safety issues, and remains dependent on costly one-off independent or public enquiries to learn from the most serious failures, such as those contributing to the tragedies at Mid Staffordshire.

Lead author Carl Macrae, Health Foundation Improvement Science Fellow, Imperial College London, said: "Inquiries can have considerable impact and provide much-needed public explanation after terrible events. However, each investigation starts anew and struggles to develop a methodology and approach, rather than building on systematic and established methods of safety investigation." He added: "Inquiry teams are short-lived and are dissolved once the report is complete; they therefore have no capacity to independently review progress against recommendations."

Safety-critical industries such as aviation, shipping and the railways all face the risk of major failures causing tragic loss of life. Each of these industries is served by an independent and permanently staffed organisation that is explicitly charged with investigating serious safety risks and major failures. A similar agency is needed for the NHS, say the authors, describing a lean organisation operating with a relatively small budget, ready to initiate investigations within hours when required. Charles Vincent, Health Foundation Professorial Fellow, University of Oxford and co-author of the paper, said: "First and foremost such an agency needs to be authoritative and open in its practices and recommendations", adding that the agency should be charged with independently monitoring the implementation of recommendations, over years if necessary.

Macrae added: "Patients and the public deserve better than the current models of investigation in the NHS, none of which have the remit, capacity or authority to routinely drive system-wide and top-to-bottom learning. Establishing a truly independent, expert investigative body would allow the NHS to rigorously investigate and routinely improve safety across the entire healthcare system."


Notes to editors

Learning from failure: the need for independent safety investigation in healthcare (DOI: 10.1177/0141076814555939) by Carl Macrae and Charles Vincent will be published by the Journal of the Royal Society of Medicine at 00:05hrs (UK time) on Friday 31 October 2014.

For further information or a copy of the paper please contact:

Rosalind Dewar
Media Office, Royal Society of Medicine
DL +44 (0) 1580 764713
M +44 (0) 7785 182732

The JRSM is the flagship journal of the Royal Society of Medicine and is published by SAGE. It has full editorial independence from the RSM. It has been published continuously since 1809. Its Editor is Dr Kamran Abbasi.

The Health Foundation is an independent charity working to improve the quality of healthcare in the UK. It exists to support people working in healthcare practice and policy to make lasting improvements to health services. The Health Foundation carries out research and in-depth policy analysis, runs improvement programmes to put ideas into practice in the NHS, supports and develops leaders and shares evidence to encourage wider change.

SAGE is a leading international publisher of journals, books, and electronic media for academic, educational, and professional markets. Since 1965, SAGE has helped inform and educate a global community of scholars, practitioners, researchers, and students spanning a wide range of subject areas including business, humanities, social sciences, and science, technology, and medicine. An independent company, SAGE has principal offices in Los Angeles, London, New Delhi, Singapore and Washington DC.

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