Findings and safety recommendations

Our investigations produce findings that identify where action can be taken to improve patient safety. These are shared in full in our reports, which are published in the patient safety investigations section.

Our findings include:

  • safety recommendations
  • safety observations
  • safety actions
  • local-level learning.

Safety recommendations

Safety recommendations are made to organisations and bodies best placed to take action to address a risk to patient safety at the national level. We do not make safety recommendations to local healthcare organisations. We do not have legal powers to enforce our safety recommendations.

The organisations we make safety recommendations to are named in our report. These organisations are asked to respond to our safety recommendations within 90 days and their responses are published on our website for transparency.

Where we do not receive a response to our safety recommendations, we work with organisations to make sure a response is provided. If no response is provided, we state this on the investigation page and what we have done to raise this concern with the wider healthcare system.

Safety observations

A safety observation describes important learning that can help to improve safety, and these are highlighted in our reports. A safety observation is usually made where the issue falls outside the key lines of enquiry for the investigation or where there is no national organisation best placed to do this work.

We may also make safety observations where we have not been able to find enough evidence to make a safety recommendation. Where this is the case, we can revisit a safety observation once we have more evidence to turn this into a safety recommendation.

Safety actions

A safety action describes an action a national organisation has completed to address a safety issue we raised during an investigation. Where an organisation completes work before our investigation is published, we credit this action in our reports to reflect the work that has been done. Without this work being completed we would likely have made a safety recommendation.

Local-level learning

HSSIB investigations may identify local-level learning for healthcare organisations or staff. This can include prompts or questions to help identify and think about how specific patient safety concerns could be responded to at the local level.

HSSIB investigation reports may also identify specific learning for integrated care systems where a more joined up, regional response to a patient safety concern could help to improve care.