The HSSIB found the ICB and NHS trusts involved lacked a shared understanding of how the pathway should operate in practice and identified gaps in how safety is managed across organisational boundaries. Risks were not always shared, accountabilities were unclear and oversight arrangements were limited, reducing the ability of the ICB to take a proactive approach to managing patient safety. 

Variation in data collection and limited information sharing further hindered understanding of how the pathway was performing, which meant that none of the organisations involved had a full picture of patient safety across the regional care pathway, the HSSIB said.

Deinniol Owens, deputy director of investigations at HSSIB, said: ‘Patient safety should be at the forefront of decision making and proactively monitored across regional care pathways. Where there is no shared understanding of roles, responsibilities and risks, it becomes harder for NHS staff to make consistent decisions about patient care.  

‘As our previous work on safety management systems reinforces, if organisations face challenges in co-ordinating activity to support patient care, accountability and responsibility can become misaligned. This leads to gaps in the oversight of safety and risks to patients and NHS staff. We are grateful to the organisations involved in the pilot for supporting us to test this new approach and share this important safety learning.'

HSSIB called on NHS leaders to clarify accountability, improve data sharing and support a more coordinated approach to managing patient safety across regional care pathways.