HSSIB Patient Safety Investigations

6 Aug 2026 Launched The use of Ambient Voice Technology in hospitals

Adoption of Ambient Voice Technology (AVT) is accelerating while the safety implications are not fully understood. This investigation will focus on acute adult secondary care …

4 Aug 2026 Launched Care of children waiting for access to child health community services

There is widespread concern about child health community services presenting some of the longest waits in the healthcare system and these delays contributing to lasting …

22 Jul 2026 Launched Deterioration in adults with a learning disability in primary care

This investigation will explore the care adults with a learning disability receive in primary care when their health is deteriorating or they have new symptoms. …

21 Jul 2026 Launched Identifying and supporting mental health problems in children via general practice

We have launched an investigation exploring how mental health problems in children are identified and supported via general practice. This is due to widespread concern …

29 Jun 2026 Launched Safety accountability and oversight thematic review

This thematic review considers safety accountability and oversight across all HSIB and HSSIB investigations to date. It provides an opportunity to identify which patient groups …

13 Jan 2026 Launched 4 scope Electronic patient record systems – electronic referrals for ongoing care

We have launched an investigation that explores risks to patient safety where electronic patient record (EPR) systems, introduced to support referrals for patient care, have …

13 Jan 2026 Launched 4 scope Electronic patient record systems – risk from loss of functionality

We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems …

4 Nov 2025 Launched The prescribing of lithium for bipolar disorder

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the …

13 Aug 2026 Published 1 rec Insulin: supporting safe self-administration for patients in the community with a learning disability

This report is the third in a series considering the self-administration of insulin by people with diabetes mellitus (diabetes) in community settings. Each report in …

13 Aug 2026 Published 1 rec Insulin: supporting safe self-administration in vulnerable patient groups in the community

This series of reports explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of …

30 Jul 2026 Published Mental health: physical health deterioration while under the care of a low secure unit

HSSIB has modelled an approach to investigating patient safety events under the NHS Patient Safety Incident Response Framework (PSIRF). This report considers the care of …

30 Jul 2026 Published 4 areas Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)

These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing …

25 Jun 2026 Published 3 recs 2 obs Online prescribing: challenges and opportunities to improve patient safety

This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.

18 Jun 2026 Published 20 prompts Patient safety across regional care pathways: learning from an HSSIB investigation pilot

We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are …

28 May 2026 Published 5 recs 3 obs Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals

This is the fourth investigation looking at medication related harm, exploring the safety issues associated with medication not given. Medication is the most common intervention …

28 May 2026 Published 3 recs Medication related harm

Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We …

19 May 2026 Published 2 recs 1 obs 13 prompts Insulin: supporting safe self-administration for patients in the community with a disability

Diabetes is one of the most common chronic diseases in England and the number of people with the condition is on the increase. It is …

23 Apr 2026 Published 4 areas Mental health: attempted suicide while under the care of community services

The is the first of three investigations to provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out …

2 Apr 2026 Published 5 recs Healthcare provision in prisons

We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our four investigation reports in this series span emergency care response, …

2 Apr 2026 Published 3 recs Healthcare provision in prisons: needs assessments and disability access

This is the final report that covers needs assessments and physical disability access, which were identified as patient safety risk areas during the investigation. Prison …

26 Mar 2026 Published 3 recs 2 obs Insulin: supporting safe administration in inpatient settings

This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one …

26 Feb 2026 Published 3 recs 2 obs Insulin: supporting safe self-administration for patients in the community with a mental health problem

This investigation explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because …

8 Jan 2026 Published 1 obs 11 prompts Patient care in temporary care environments

This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.

27 Nov 2025 Published 1 obs 13 prompts Electronic patient record (EPR) systems – thematic review

We have completed a thematic review of 50 HSSIB reports to identify specific patient safety issues and learning related to electronic patient record (EPR) systems. …

30 Oct 2025 Published 1 rec 12-lead electrocardiograms (ECGs) in ambulance services

These two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction …