Source · Patient safety investigations
HSSIB Patient Safety Investigations
HSSIB conducts independent investigations into patient safety concerns across England's NHS, producing safety recommendations directed at named organisations. Data sourced from hssib.org.uk.
165 investigations349 recommendations indexed307 recommendations with responses
Investigations
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 …
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 …
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 …
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 …
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'.
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 …
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to adults — HSSIB
Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare
Independent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning
The aim of this interim report is to highlight the importance of staff in mental health inpatient units and community mental health services, taking a …
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
Healthcare provision in prisons: emergency care response — HSSIB
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
Three reports that model investigation of sepsis under the Patient Safety Incident Response Framework (PSIRF), to boost local learning and help improve investigation quality in …
Digital tools for online consultation in general practice
Full online version of the Health Services Safety Investigations Body (HSSIB) investigation report 'Workforce and patient safety: digital tools for online consultation in general practice'.
Clinical investigation booking systems failures: written communications in community languages — HSSIB
Keeping children and young people with mental health needs safe: the design of the paediatric ward
This investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health …
Keeping children and young people with mental health needs safe: the design of the paediatric ward — HSSIB
Patients at risk of self-harm: continuous observation
This investigation has found limited evidence that the current approach to continuous observation of adult patients at risk of self-harm on hospital wards is effective.
Nutrition management of acutely unwell patients in acute medical units
Acute medical units (AMUs) are the first point of entry for patients referred to hospital as an emergency by their GP and those who require …
Investigation report: Retained swabs following invasive procedures
Full online version of the Health Services Safety Investigations Body (HSSIB) report 'Retained swabs following invasive procedures: themes identified from a review of NHS serious …
Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports
Retained swabs are classed as Never Events. Data shows there has been 11-23 retained swab incidents per year since 2015. The investigation was launched after …
Fatigue risk in healthcare and its impact on patient safety
The purpose of this report is to introduce the concept of fatigue and the risk it poses to patient safety. It also outlines the investigation …
Temporary staff – involvement in patient safety investigations
Full online version of the Health Services Safety Investigations Body (HSSIB) investigation report 'Workforce and patient safety: temporary staff - involvement in patient safety investigations'.
Positive patient identification
We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and …
Advanced airway management in patients with a known complex disease
This investigation explores intubation of patients with difficult airways. There are no standards for how an anticipated difficult airway is managed. Failure to provide an …
Interim report: Retained swabs following invasive procedures
Full online version of the Health Services Safety Investigations Body (HSSIB) interim report 'Retained swabs following invasive procedures: themes identified from a review of NHS …
165 investigations
349 recommendations
284 observations
70 actions
264 learning prompts
23 improvement areas
4 scope items
307/349 responded
Indexed output types
Read the chart values
| Output type | Items |
|---|---|
| Safety recommendations | 349 |
| Observations | 284 |
| Safety actions | 70 |
| Learning prompts | 264 |
| Areas of improvement | 23 |
| Investigation scope | 4 |
Key findings
This collection contains 165 patient safety investigations,
producing 349 safety recommendations, 284 observations
and 70 safety actions, alongside 264 local learning prompts, 23 areas of improvement, and 4 scope items.
88% of safety recommendations have received a published response.