HSSIB Patient Safety Investigations

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 …

10 Jul 2025 Published 2 recs 1 obs 19 prompts Workforce and patient safety: electronic communications on patient discharge from acute hospitals

This is the fifth investigation report that considers how working conditions in the NHS can be optimised to support patient safety, while maintaining and improving …

26 Jun 2025 Published 5 areas Sepsis: a patient with abdominal pain

This is the third investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …

26 Jun 2025 Published 3 areas Sepsis: a patient with a urine infection

This is the second investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …

26 Jun 2025 Published 2 areas Sepsis: a patient with diabetes and a foot infection

This is the first investigation report we have published to help address patient safety risks associated with sepsis. To support NHS organisations in investigating these …

13 May 2025 Published 5 recs Mental health inpatient settings

This series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. …

13 May 2025 Published 2 recs 1 obs Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for Health and Social Care

This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023, launched in January 2024 and completed …

24 Apr 2025 Published 2 recs 5 obs 10 actions 10 prompts The impact of staff fatigue on patient safety

Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share …

10 Apr 2025 Published 2 recs 1 obs Workforce and patient safety: primary and community care co-ordination for people with long-term conditions

This is the fourth of five investigation reports that consider how working conditions in the NHS can be optimised to support patient safety, while maintaining …

27 Mar 2025 Published 1 rec 4 obs 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence

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

13 Mar 2025 Published 10 prompts Medication not given: anticoagulation before and after a procedure

This is the second of three locality-based patient safety investigation reports, which presents the findings of an investigation into a patient safety event at an …

13 Feb 2025 Published 1 rec 2 obs 2 actions Safety management

This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff …

30 Jan 2025 Published 5 recs 4 obs Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge

This series of investigations was announced by the Secretary of State for Health and Social Care in June 2023. We can look at inpatient mental …

12 Dec 2024 Published 5 recs 4 obs Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services

This is the third report in a series of patient safety investigations looking at mental health inpatient settings. They were announced by the Secretary of …

5 Dec 2024 Published 1 obs 18 prompts Medication not given: administration of time critical medication in the emergency department

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

28 Nov 2024 Published 3 recs 4 obs Healthcare provision in prisons: continuity of care

This investigation focuses on the continuity of care for patients in prison. In the context of this investigation, ‘continuity of care’ means maintaining a patient’s …

21 Nov 2024 Published 2 recs 6 obs Investigation report: Mental health inpatient settings - out of area placements

Final report for the Health Services Safety Investigations Body (HSSIB) investigation 'Mental health inpatient settings: out of area placements'.

31 Oct 2024 Published 3 obs Sexual safety: the implications for patient safety

There is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, HSSIB carried out exploratory work to consider the …

24 Oct 2024 Published 5 recs 5 obs Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB