Health Services Safety Investigations Body

We investigate patient safety concerns across England to improve NHS care at a national level.

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Latest investigation reports

A male wheelchair user is unable to use an internal staircase for access to the next level.

Healthcare provision in prisons: needs assessments and disability access

This investigation focuses on how the health needs of people in prison are assessed and the provision of safe living conditions for people in prison who use a wheelchair or have mobility issues. Our latest investigation highlights serious risks faced by wheelchair users and people with mobilit…

Read the prison healthcare report
A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Insulin: supporting safe administration in inpatient settings

This investigation focuses on the safety of patients in hospital in England who have diabetes requiring treatment with insulin. Insulin is a high-risk medication and is among the most common causes of harm from medication errors in the NHS.

Read the inpatient insulin report
A young diabetic woman holds a syringe pen to inject insulin.

Insulin: supporting safe self-administration for patients in the community with a mental health problem

Our safety recommendations are designed to strengthen care for people with co-existing mental health conditions and insulin-treated diabetes, with a clear focus on improving integration between services and advancing recognition and research into type 1 diabetes and disordered eating.

Read the community insulin report

About us

We aim to be the global leader in professional, high quality healthcare safety investigations. We investigate patient safety concerns across England to improve NHS care at a national level. Our investigations do not find blame or liability with individuals or organisations. Information shared with us is confidential and protected by law.


We are a fully independent arm’s length body of the Department of Health and Social Care.

Find out more about us
A blurred hospital corridor with a healthcare professional walking away and a drip stand in the foreground.

Investigations

We can investigate patient safety concerns that occur in England during the provision of healthcare services, and that have or may have implications for the safety of patients.

Our investigations can consider healthcare provided in the NHS and the independent sector. Where an investigation relates to an incident that did not occur in the NHS, we must consider whether NHS systems and practices could be improved because of our investigation.


We can also be directed to investigate a patient safety concern by the Secretary of State for Health and Social Care.

View our patient safety investigations
A female healthcare professional talks to a female safety investigator on a busy hospital ward.

Building investigation excellence

We have launched a new strategy to help meet the demands of a changing patient safety landscape.


‘Building investigation excellence: our strategy for strengthening the capability of healthcare investigations’ will be instrumental in supporting investigators across the NHS in England to carry out high-quality investigations that drive real improvements in patient safety.

'Building investigation excellence' strategy

News, events and blogs

A male wheelchair user is unable to use an internal staircase for access to the next level.

Wheelchair users in prisons facing harm and dignity concerns due to inaccessible environments

Our investigation highlights that wheelchair users and people with mobility issues in prisons are being put at risk of physical harm, psychological distress and avoidable dignity violations due to in…
Read the full article
A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.

Persistent risks to safe insulin care in hospitals

Patients with diabetes who rely on insulin are facing persistent and serious safety risks when admitted to hospital, according to our latest investigation report.
Read the full article
A female healthcare professional talks to a female safety investigator on a busy hospital ward.

New blueprint for healthcare investigators could save lives

A first-of-its-kind framework has mapped the exact skills and qualities healthcare safety investigators need to prevent repeated harm to patients, offering a way forward from the old-style blame and …
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