We investigate patient safety concerns across England to improve NHS care at a national level.
This investigation demonstrates how mental health patient safety incidents can be examined under the NHS Patient Safety Incident Response Framework (PSIRF), using a case from community mental health services as a learning example.
There is currently no clear legal power to lawfully prevent vulnerable individuals from leaving the emergency department while they are waiting for assessment or admission. This exposes people in mental health crisis to increased risk of harm and creates challenging conditions for staff.
This investigation highlights serious risks faced by wheelchair users and people with mobility issues in prisons, including physical harm, psychological distress and avoidable violations of dignity. These risks stem from inaccessible accommodation and outdated assessments of healthcare needs.
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.
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.
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.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
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