We investigate patient safety concerns across England to improve NHS care at a national level.
This report is the fourth and final report in a series considering the self-administration of insulin by adults with diabetes mellitus (diabetes) in community settings. Each report in the series focused on specific groups of people who, due to their circumstances, may be at increased risk of h…
This report highlights a risk to patient safety associated with the electronic referral service (e-RS), where referrals may be removed from healthcare provider organisation worklists without warning or recognition. We have included local level learning prompts to help provider organisations re…
People experiencing a mental health crisis are too often being cared for in emergency departments that are not designed, equipped or resourced to meet their needs. Action is required to support safe, therapeutic care in emergency departments alongside wider changes across the care pathway.
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 online Knowledge Exchange designed to improve access to practical guidance, learning and expertise for those involved in patient safety investigations.
The new resource is intended to support a wide audience, including patient safety specialists, healthcare professionals, commissioners and policymakers, as well as staff, patients, families and carers involved in investigations.
The Knowledge Exchange is part of our work to implement 'Building investigation excellence: our strategy for strengthening the capability of healthcare investigations’.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
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