INTRODUCTION

  1.  Following the Newsnight programme on 23 November, the Committee asked HSE to confirm that there are no similar cases to that of Mr Hince in the North West, nor indeed in any other operational region of the HSE. If it is not possible to provide these assurances, the Committee asked for an explanation of why.

REVIEW

  2.  We presume that what the Committee intends by "cases similar to Mr Hince's" are reported accidents involving serious injury that were not investigated by HSE. Since 23 November HSE has carried out a quality assurance review of decisions on investigation of major injury accidents. A sample of 1,007 cases was selected randomly from the total of approximately 14,900 reports of serious injury to workers and members of the public received by HSE's Field Operations Directorate between April and September 1999 which had not been investigated. The decision not to investigate in these sample cases was reassessed against the Health and Safety Commission and Executive's criteria of accident investigation. The work was carried out regionally by groups of senior inspectors not involved in the original decisions.

RESULTS

  3.  From the sample, 953 cases (95 per cent) were considered to have been correctly assessed against the current criteria. Of the remaining 54 accident reports, 39 fell within the criteria but had not been selected for investigation on the grounds that at the time there were other higher priorities for the inspector resources available (such as the investigation of other serious accidents, and prosecutions). In each of these cases the reviewers looked at the circumstances at the time and concluded that the decision was soundly based within the discretion afforded to local operational managers. Subsequently these 39 cases have been referred to Regional Heads of Operations for an assessment. These cases will be investigated if this further review indicates, in retrospect, that inspector resources should have been found by re-deployment from other work. In 15 cases the reviewers considered that the original decision not to investigate was wrong. These cases are all now under investigation.

  4.  In addition to the immediate work arising from the review, HSE's Field Operations Directorate is taking a number of actions to improve the quality of its decision-making on investigation. It will:

—  give priority to completing existing work to bring its accident investigation procedures within a formal quality management system;

—  institute routine quality reviews of samples of decisions;

—  record reasons for investigating or not investigating, to assist audit or review;

—  refer to Heads of Operations any decision not to investigate which is based on resource consideraions;

—  ensure that responses to enquiries from solicitors about serious accidents which have NOT been investigated are authorised by Heads of Operations.

  5.  It is not possible to give a categorical assurance that there are no other cases which should have been investigated in accordance with HSC/E guidance, to add to the 15 identified by the sampling exercise. Use of scarce resources to review decisions in the other 13,900 non-investigated major injury cases in the period April-September 1999 would not be justified given the 1.5 per cent error rate from the sample. None of the wrong decisions identified in the sample was in the North West Region.