HSSIB Patient Safety Investigations

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 …

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 …

19 May 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 …

23 Apr 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 …

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 …

30 Oct 2025 Published 2 recs 4 obs 12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI) — HSSIB

This is the second investigation to help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated …

9 Oct 2025 Published 14 prompts Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

This report shares our learning about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It's intended for national and local organisations …

16 Sep 2025 Published 2 recs Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

Mental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the …

19 Aug 2025 Published An exploratory review of maternity and neonatal services

This report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved …

14 Aug 2025 Published 17 prompts Medication not given: discharge from an acute hospital to the community

This is the third investigation report into medication related harm. Medication is the most common intervention for patients in the NHS. In the most serious …

24 Jul 2025 Published 4 recs Healthcare provision in prisons: data sharing and IT

This is the third of a series of HSSIB reports on the theme of healthcare provision in prisons. The first report explored emergency care response, …

10 Jul 2025 Published 3 recs Workforce and patient safety

The workforce challenges faced by the NHS in England present a risk to patient safety and staff wellbeing. We've undertaken five investigations to consider how …