We investigate patient safety concerns across England to improve NHS care at a national level.
This report shares learning from a pilot of a new rapid investigation process that examined a redesigned regional care pathway. It warns that unclear roles, limited oversight and inconsistent information sharing can limit how risks are identified and managed across NHS organisations.
NHS trusts are managing complex digital safety risks related to ePMA, with significant unwarranted variation in how this software is designed, procured and regulated across acute hospitals. This could increase the risk of medication related harm to hospital patients if it’s not addressed.
People with diabetes and a disability may be left without the support they need to safely administer insulin at home – creating life-threatening risks. Community support can be fragmented, with services not always working together to recognise changing needs and make reasonable adjustments.
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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