Not involving temporary NHS staff, including bank, agency and locum workers, in serious incident investigations may put patient safety at risk, according to the UK’s Health Services Safety Investigations Body.

In a report, the watchdog highlighted how leaving temporary staff out of patient safety investigations could lead to system-wide problems going "unrecognised" which could mean patient safety incidents could be repeated.

A patient safety incident investigation occurs when patient safety risks are highlighted by an incident or a "near miss".

The watchdog examined 30 ‘serious incident investigations’ from May 2022 to May 2023 where temporary staff had been involved in the incident. In 18 of the 30 reports the locum, bank or agency staff who were involved in the incident were not involved in the subsequent investigation, and in a further four reports it was unclear whether there had been such involvement.

It added that this could be for a number of reasons, including hospital investigation teams finding it difficult to contact agency staff as their details are held externally.

The investigation explored the challenges of involving temporary clinical staff in local trusts’ patient safety investigations.

“Trust-level investigations are important because they are a way to identify learning to improve healthcare systems, with the aim of reducing the potential for harm to patients,” the report stated.

Meanwhile, some NHS trusts told HSSIB that the investigation of incidents involving temporary staff can be "less thorough".

The new HSSIB report also suggests that temporary staff at many trusts are not able to report these incidents when they happen under their watch. The HSSIB has made two recommendations to NHS England to help temporary staff be more engaged with patient safety investigations.

Matthew Mansbridge, HSSIB 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,” Mansbridge added.

"Consistency is needed at both a national and local level in relation to the involvement of temporary staff,” Mansbridge continued. “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.”

An NHS England spokesperson said, "It is crucial that all staff, including agency workers, are involved in serious incident investigations so their vital insights contribute to learning. We have already updated the guidance we give to healthcare providers to reflect the HSSIB recommendations and will make further changes as needed."