Patient safety investigation figures

Response

HSSIB holds some of the information requested. We have responded to each question below and, where information is not held in a centrally recorded format, we have explained this as clearly as possible.

During 2025:

1) How many investigations were completed?

Between 1 January and 31 December 2025, HSSIB published 17 investigations.

2) Of those investigations how many were initiated after concerns expressed by an NHS organization?

Listening to concerns raised by NHS organisations is vital information we use to decide what to investigate. We hear these concerns both from staff working in the services, but also from national organisations such as NHS Alliance who represent providers and ICBs, and other national stakeholders who work with NHS organisations.  We increasingly are being approached by NHS organisations when we launch an investigation to ask to feed into the investigation process.

Our investigations are not usually initiated in response to a single concern or referral. Instead, decisions about which issues to investigate are informed by intelligence gathered and considered from a range of sources. We therefore do not categorise completed investigations according to whether they were initiated by an NHS organisation, a non-NHS organisation or an individual.

Further information about how we identify and undertake investigations is available on the HSSIB website here: How we investigate.

3) Of those investigations how many were initiated after concerns expressed by an organization, which was not part of the NHS?

We work extensively with a wide range of national stakeholders who raise concerns with us, including the Independent Health Providers Network, Royal Colleges and the Academy of Royal Colleges and the voluntary sector. However, we do not categorise completed investigations according to whether they were initiated by an NHS organisation, a non-NHS organisation or an individual.

4) Of those investigations how many were initiated after concerns expressed by an individual person?

HSSIB welcomes information and concerns raised by patients, families, carers, healthcare staff, and organisations. These contributions can provide valuable insight into potential patient safety issues.

Our investigations are not usually initiated in response to a single concern or referral. Instead, decisions about which issues to investigate are informed by intelligence gathered and considered from a range of sources. We therefore do not categorise completed investigations according to whether they were initiated by an NHS organisation, a non-NHS organisation or an individual.

Further information about how we identify and undertake investigations is available on the HSSIB website here: How we investigate.

5) On how many occasions did investigators interview patients?

Insight provided by patients, carers and families who contribute to our investigations is vital for our work. Hearing directly from those impacted by safety concerns helps our investigators understand their experiences and consider how care was delivered in practice. We also work with advocacy groups such as AvMA, Healthwatch and the Patients Association and voluntary sector organisations to hear their views. Also, during the course of an investigation, investigators visit multiple sites to observe practice, and during these visits will engage with patients using the service. All of our investigators have trauma informed engagement training to support a compassionate approach to working with patients and families impacted by harm.

Information about the people who contributed to individual investigations is provided, where appropriate, in the appendices to our published investigation reports. However, HSSIB does not hold a centrally collated record of the total number of patients interviewed.

Please note, in respect of Questions 5, 6, 7, 8 and 9, the following is true. Providing the requested total would require a manual review of individual investigation records. We estimate that this work would exceed the appropriate cost limit of 18.5 hours. HSSIB is therefore applying the exemption under section 12 of the Freedom of Information Act 2000 to these parts of the request.

6) On how many occasions did investigators interview NHS staff?

Hearing from staff is a fundamental part of an investigation and we work with a wide range of staff across multiple sites during the course of a single investigation. This is vital for us to understand safety risks in more detail, as their contributions help us understand how services and systems operate and what their concerns about patient safety are.

We do not hold a centrally collated record of the total number of NHS staff interviewed.

7) On how many occasions were NHS staff required to attend an interview with investigators?

HSSIB’s preferred approach is to work collaboratively with the people and organisations involved in an investigation. We value the voluntary participation of NHS staff and recognise the important contribution they make by sharing their knowledge and experience.

If this question relates specifically to HSSIB’s statutory powers under the Health and Care Act 2022 to require a person to attend an interview, we can confirm that HSSIB has not exercised these powers and has not required any NHS staff member to attend an interview.

8) On how many occasions did investigators interview staff from non-NHS organisations?

We have undertaken investigations involving the independent sector on several occasions and have interviewed a wide range of staff members in this sector to understand their patient safety concerns. We also work with a wide range of non NHS organisations including DHSC teams, wider government departments, organisations such as the British Standards Institute, regulatory bodies, Royal Colleges and voluntary sector organisations.

We do not hold data as to how many individuals we have interviewed from the non-NHS sector.

9) On how many occasions were non-NHS staff required to attend an interview with investigators?

HSSIB seeks to engage constructively and collaboratively with everyone who contributes to an investigation. We value the voluntary participation of staff from non-NHS organisations and the insight they provide.

If this question relates specifically to HSSIB’s statutory powers under the Health and Care Act 2022 to require a person to attend an interview, we can confirm that HSSIB has not exercised these powers and has not required any member of staff from a non-NHS organisation to attend an interview.

10) On how many occasions did investigators enter premises and seize documents?

HSSIB has not exercised its statutory powers to enter premises and seize documents during the period covered by the request.

11) On how many occasions did investigators enter premises and seize equipment?

HSSIB has not exercised its statutory powers to enter premises and seize equipment during the period covered by the request.

12) On how many occasions did investigators enter private homes with the owner’s consent?

HSSIB does not hold a centrally collated figure for visits to private homes.

Where an investigator meets a patient, family member or carer in their home, the visit takes place with their consent. We offer alternative meeting arrangements if patients, carers or families request it. We recognise that inviting an investigator into a person’s home is a significant act of trust, and we aim to conduct these conversations respectfully and sensitively.

13) How many occasions were cases taken to a magistrate’s court?

No cases were taken to a magistrates’ court.

14) On how many occasions did such a case lead to a conviction?

There were no convictions.

15) When there was a conviction, how much was the fine?

As there were no convictions, no fines were imposed.

16) On how many occasions did HSSIB assist with investigations outside of England?

HSSIB did not assist with any investigations outside England during the period covered by the request. However, we work extensively with international colleagues to share the learning from our work and to learn from patient safety work happening elsewhere.  HSSIB has established a global network called IPSON which enables this. We also work with the Patient Safety Commissioner in Scotland and colleagues in Wales and Northern Ireland to share learning.

17) On how many occasions did HSSIB assist with investigations outside of the UK?

HSSIB did not assist with any investigations outside the UK during the period covered by the request. However, as above, we have mechanisms to share learning from other countries.

18) What external organization, if any, provides training for Investigators?

Following clarification received on 23 September 2026, we understand that this question relates to training on:

• Interviewing people who have been requested to attend an interview.
• Conducting an investigation involving entry to premises and taking control of or removing documents or equipment.

HSSIB’s interview training applies to engagement with anyone who contributes to an investigation and is not limited to people who may be required to attend an interview. The most recent training was delivered internally. We also ensure our investigations have trauma informed engagement training. We have developed a competency framework for investigators that we use internally to ensure our investigators are all trained to a high and consistent standard.

Training and guidance on the conduct of investigations, including the use of HSSIB’s statutory powers under the Health and Care Act 2022, are also provided internally. Investigators are supported by guidance contained within HSSIB’s Operational Manual. Therefore, no external organisation currently provides the specific training described in this question.

19) How much was the funding allocated to HSSIB in 2025?

HSSIB’s revenue budget was £6.3 million for 2025/26.