Recommendation 44: Establish framework for future investigations
From Report of the Morecambe Bay Investigation, published 3 March 2015.
Recommendation
This Investigation was hampered at the outset by the lack of an established framework covering such matters as access to documents, the duty of staff and former staff to cooperate, and the legal basis for handling evidence. These obstacles were overcome, but the need to do this from scratch each time an investigation of this format is set up is unnecessarily time-consuming. We believe that this is an effective investigation format that is capable of getting to the bottom of significant service and organisational problems without the need for a much more expensive, time-consuming and disruptive public inquiry. This being so, we believe that there is considerable merit in establishing a proper framework, if necessary statutory, on which future investigations could be promptly established. This would include setting out the arrangements necessary to maintain independence and work effectively and efficiently, as well as clarifying responsibilities of current and former health service staff to cooperate. Action: the Department of Health.
In brief (written by this site)
The Department of Health and Social Care and NHS England reported in commentary published in February 2026 that the Health Services Safety Investigations Body was established in April 2023 with statutory processes for evidence handling and document access, alongside a national internal investigation framework (DHSC and NHS England, Feb 2026). Minister of State Karin Smyth similarly confirmed these arrangements in November 2024 (Karin Smyth, Nov 2024). Previously, the Thirlwall Inquiry legal team found in May 2024 that the recommendation had been clearly implemented (The Thirlwall Inquiry legal team, May 2024).
Sources
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
69. We accept this recommendation in principle. A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. The Service will also respond to the concerns that had been previously subject to public inquiries or national investigations, such as Mid-Staffordshire NHS Foundation and University Hospitals Morecambe Bay NHS Foundation Trust. We intend to establish an expert advisory group who, over the coming months, will advise on the purpose and function of the new Independent Patient Safety Investigation Service. As part of this work, we will build on the useful insights that participants in this Investigation have shared. 70. We agree that independent non-statutory investigations provide a useful, more rapid and potentially more efficient alternative to statutory public inquiries as a last resort for investigating failings in care. This route has now been well tested and has the benefit of being able to engage with affected families, ensuring their key concerns are built into the Terms of Reference and can therefore be addressed by the investigation/ panel; and of not being a legal process which can inhibit people's willingness to engage openly and candidly. 71. We are considering whether we can use, or build on, the central Cabinet Office support provided to inquiries, including guidance for each stage of the inquiry, useful documents and access to a Whitehall officials' and former inquiry secretaries' network, and which is currently being updated and considered by a cross-Government group.
How this response relates to the recommendation
Site note: This is the Department of Health's response, "Learning not blaming" (Cm 9113, July 2015), to the Morecambe Bay Investigation and two other reports. The department has been the Department of Health and Social Care since January 2018, and the rows are filed under that name. Every word is the department's, including where it reports what another body has done or will do.
Delivery
DHSC and NHS England say in progress (27 February 2026)
The Thirlwall Inquiry has noted action taken in response to this recommendation.
The Healthcare Safety Investigation Branch (HSIB) became an independent investigations body known as the Health Services Safety Investigations Body (HSSIB) in April 2023, through the Health and Care Act 2022. Its role is to investigate incidents occurring during the provision of health care services that have or may have implications for patient safety. The HSSIB will conduct investigations using a no-blame approach; this is supported by ‘safe space’ which encourages participants, including patients, families and staff, to share information in confidence. This aims to encourage the spread of a culture of learning within the NHS and independent sector. As set out in the Act, the HSSIB will also provide advice, guidance, and training to NHS bodies upon request.
HSSIB have established their own processes and principles around matters such as evidence handling and access to documentation. These processes are supported by provisions in the Health and Care Act, particularly on protected material, criteria, principles, and processes.
Please see response to recommendation 39 for details about the Maternity and Newborn Investigations Programme’s which investigates early neonatal deaths, intrapartum stillbirths and severe brain injury in babies born at term following labour in England, and maternal deaths in England.
NHS England has created a National Independent Patient Safety Investigation Framework (NIPSIF), which is an internally focussed approach to support the commissioning and management of independent investigations.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Ongoing”. Table row: section 23.2 No. 44, PDF page 657.
Department of Health and Social Care says in progress (25 November 2024)
The Government is committed to ensuring that all women and babies received safe, personalised, equitable, and compassionate care. We are determined to learn lessons from inquiries and investigations.
The Healthcare Safety Investigation Branch became an independent investigations body known as the Health Services Safety Investigations Body (HSSIB) in April 2023, through the Health and Care Act 2022. Its role is to investigate incidents occurring during the provision of health care services that have, or may have, implications for patient safety. The HSSIB will conduct investigations using a no-blame approach, that is supported by a safe space which encourages participants, including patients, families, and staff, to share information in confidence. This aims to encourage the spread of a culture of learning within the National Health Service and independent sector.
As set out in the Health and Care Act 2022, the HSSIB will also provide advice, guidance, and training to NHS bodies upon request. The HSSIB has established their own processes and principles around matters such as evidence handling and access to documentation.
NHS England has created a National Independent Patient Safety Investigation Framework, which is an internally focussed approach to support the commissioning and management of independent investigations.
Earlier statement on delivery (1)
Department of Health and Social Care (2 March 2020)
The Healthcare Safety Investigation Branch was established in 2017 to investigate to improve patient safety and create a learning culture across the National Health Service.
The Health Service Safety Investigations Bill was introduced in the previous Parliament. This legislation will establish a fully independent arms-length patient safety investigation body, create a statutory ‘safe space’ in this body and provide the new body with powers to discharge its investigative function effectively. These include the power to ask individuals, to attend to answer questions or to provide information, documents equipment or other information as required.
The Department will bring forward these proposals when Parliamentary time allows.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
Department of Health response (July 2015):
A new Independent Patient Safety Investigation Service will conduct independent, expert-led investigations into patient safety incidents. (p. 82)
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 20.2 No. 44, PDF page 627.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding