Patient Safety Review

Debate between Anna Dixon and Bernard Jenkin

Monday 6th July 2026 Commons Chamber

[Sir Bernard Jenkin]

I thank the hon. Gentleman.

Recommendation 1 in the Dash review says that the new National Quality Board should

“avoid unfunded mandates being imposed on the system without due consideration”.

Public inquiries have certainly made well meaning but unaffordable recommendations—I think of the Francis inquiry recommendation on blanket standards for minimum staffing—but it is wrong to see safety as a cost in opposition to other benefits. The cost of safety failures is astronomic, with NHS clinical negligence costing £3.6 billion a year, despite all the public inquiries. Effective safety management is about the cost-effective management of risk, not risk elimination at any cost. If the air accidents investigation branch did not balance costs with effective risk management, aeroplanes would not fly. Can the Minister therefore point out which of HSSIB’s recommendations have been too expensive to implement? If not, where is the justification for abolishing HSSIB?

Neither the NQB nor the CQC should control investigations. The AAIB cannot be prevented from making independent recommendations by the Civil Aviation Authority, the Transport Secretary or airlines themselves. Why should the NQB, which will be subject to political direction, be allowed to decide what safety recommendations should be made and what should be investigated, as Dash recommends?

On page 31, Dash incorrectly states:

“HSSIB was not able to retain the maternity programme because the Health and Care Act 2022 does not make provision for maternity investigations under HSSIB.”

Why have the Government accepted that assertion as true? It is wrong in fact and law. The new statutory HSSIB did not take on maternity and newborn safety investigations, because they were commenced without the safe space protections, so their evidence is available for legal proceedings. That is not how HSSIB operates. Since 2023, HSSIB has been conducting its own maternity investigations. Indeed, when the Amos review was established, it took on the relevant investigations from HSSIB and then relied on HSSIB for assistance with them.

With sufficient resources, HSSIB could conduct all maternity investigations much more effectively than the maternity and newborn safety investigations programme. Amos reported that MNSI investigations are not trusted by families, as my right hon. Friend the Member for Godalming and Ash (Sir Jeremy Hunt) was saying, and are not consistent or effective in identifying learning or providing accountability. Amos also says that families should have access to an independent investigation if they lose confidence in the local investigations. Without HSSIB, who will provide those independent investigations?

Finding 6 accuses HSSIB of having “expanded” its

“scope of work beyond the original remit…For example, HSSIB was originally established, along the lines of safety investigatory bodies in other industries, to look at specific cases or incidents of severe harm, but it has since broadened its work into making more systemic recommendations.”

That is what Dash says. It is complete nonsense. HSSIB is exactly equivalent to the AAIB, the marine accident investigation branch and RAIB, and was, like them, set up to conduct systemic investigations. That is why they are such effective bodies. The Health and Care Act 2022 does not limit HSSIB investigations to individual incidents. There is no reference whatsoever to “severe harm”, as Dash puts it, in the 2022 Act. It was always intended by Parliament that HSSIB should make systemic recommendations arising from the investigation of specific incidents or groups of incidents. I can say that with authority because it was my Select Committee that recommended HSSIB in the first place, and I also chaired the pre-legislative scrutiny Committee on the draft legislation, so how can Ministers give any authority to the Dash review, which claimed that HSSIB has expanded its remit, when it has done no such thing?

Recommendation 3 proposes:

“Most investigations into safety incidents should continue to be managed within provider organisations”.

This really is the fundamental flaw in Dash. Recent maternity investigations conducted by trusts have highlighted the deficiency of provider-led investigations, as Ockenden and Amos have pointed out. Do the Government accept that investigations by provider organisations are inherently conflicted? Just ask the clinicians, patients, families and patient safety organisations what they think about trusts marking their own homework. None of them has confidence, because providers are keen to protect themselves from litigation and reputational damage. How can Ministers accept the Dash recommendation that we should rely on investigations conducted by provider organisations?

[Anna Dixon (Shipley) (Lab)]

I commend the hon. Gentleman for speaking so clearly about why having an independent HSSIB—independent of those providers—to investigate is so important. Time and again, we hear about devastating failings in the NHS. He alludes to maternity services, but we could add to the list infected blood and pelvic mesh. Does he agree that professionals and those working inside the NHS must be able to speak freely when things go wrong in order to learn lessons, and that that is only possible with an independent investigating organisation?

[Sir Bernard Jenkin]

I thank the hon. Lady for that intervention. Only an independent investigator can find the causes of the incident that may be part of the culture or practice of that provider, or of the system as a whole. It is like suggesting that airlines or aircraft manufacturers can protect passenger safety without the independent accountability provided by the AAIB. Of course, providers should have the capacity and capability of conducting patient safety investigations, but they must know that HSSIB can and will look at that work and will hold them to account.

Recommendation 3 also says that HSSIB should continue as what it calls

“a centre of excellence for investigations”

in the CQC, but I am afraid that this is just a sop. The CQC, as was pointed out by my right hon. Friend the Member for Godalming and Ash, is a regulator and compliance enforcer, not an investigator. How can the CQC also be an independent investigator? Dash also says that the CQC internal successor should collaborate through the NQB to agree the scope of any investigations it carries out and agree the recommendations. Dash is effectively saying that CQC investigations will be overseen by the NQB. That is a direct attack on the independence of investigations.

Can the Minister explain who in future will conduct independent and unconflicted investigations into safety incidents in the NHS? For example, how would an investigation under the CQC be free to find that the CQC inspections themselves were causing unintended harm to patients, or is it back to the misery of litigation through the courts and more public inquiries?

The recommendation also makes no reference to the statutory safe space raised by the hon. Member for Shipley (Anna Dixon) that provides for protected disclosure by patients and their families, clinicians and others in safety investigation bodies. It is a crucial safeguard, allowing people to speak. It allows for the duty of candour. I would just point out that the duty of candour does not work if it is just imposed on people. People cannot be forced to incriminate themselves. If placed under the CQC, confidence in the safe space investigations will collapse—and back we go to public inquiries.

The Health Bill does attempt to address this by replicating the 2022 Act’s safe space provisions, but that Act also provided for disclosure in certain circumstances, which is allowed on the basis that the benefits for the safety of patients outweighs any impact on current and future investigations. But under this Bill, who will decide what protected information can be disclosed? How will the CQC give the same confidence that the safe space is not being compromised as HSSIB?

Finally, Dash fails to look at the comparative cost of HSSIB investigations versus the cost of public inquiries. HSSIB at the moment only costs £6.3 million per year. To save money, the Secretary of State should request that HSSIB conducts far more investigations into matters which he thinks are important, provided that he also provides the funding for the necessary capacity. HSSIB, for example, has conducted eight investigations into mental health suicides since 2023. Each was completed in a few weeks or months, costing a total of £850,000. In comparison, the Lampard inquiry into the Essex partnership university trust in my constituency—investigating the same problem—is expected to cost more than £5 million. Ockenden cost £14 million. This is very far from the best use of resources for conducting investigations.

So I ask the Minister, why have Dash and the Government ignored the whole question of HSSIB’s value for money? Even if HSSIB only saves a fraction of the £3.6 billion in costs of clinical negligence, it will pay for itself many fold. I do hope that Ministers will reconsider the whole issue, reflecting on the fact that none of the Royal colleges, nor any of the patient safety organisations, nor the all-party group on patient safety support this unjustifiable policy.