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Two people sit together at a table, raising their hands together during a shared activity, with an open notebook in the foreground. One of the people has a learning disability.
Events

Register now for learning disability listening event

30 September 2026

We're working with Learning Disability England to hear about your experience, insights and expertise relating to GP and NHS 111 care for adults with a learning disability.
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An image of a hospital waiting room with three empty seats and one seat occupied.
News

New investigation highlights prolonged waits, inadequate environments and growing pressures on mental health emergency care

17 September 2026

People experiencing a mental health crisis are too often being cared for in emergency departments (EDs) that are not designed, equipped or resourced to meet their needs, according to our new report.
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News

Response to the publication of the Thirlwall Inquiry report

15 September 2026

Today the long awaited report from the Thirlwall Inquiry has been published. The Inquiry was led by Lady Justice Thirlwall and was set up to examine events at the Countess of Chester Hospital and the…
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News

Response to the publication of the Thirlwall Inquiry report

15 September 2026

Today the long awaited report from the Thirlwall Inquiry has been published. The Inquiry was led by Lady Justice Thirlwall and was set up to examine events at the Countess of Chester Hospital and the…
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News

Our response to the National Commission's recommendations on safe adoption of AI in healthcare

10 September 2026

Today, the National Commission into the Regulation of AI in Healthcare has published its final report and recommendations setting out its vision for how the UK regulatory framework should evolve as A…
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News

Launch of Knowledge Exchange as demand for investigation expertise grows

1 September 2026

Today, 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.
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A doctor wearing blue scrubs uses a laptop. A graphic of computer folders to represent electronic patient record systems is superimposed on the photo.
News

Rapid evaluation of NHS advice and guidance services needed to protect patients

18 August 2026

NHS advice and guidance services can benefit patients but must be better implemented and more rigorously evaluated to support safe expansion, our interim report has found.
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A young diabetic woman holds a syringe pen to inject insulin.
News

HSSIB identifies inequitable support for people with a learning disability to safely self-administer insulin

13 August 2026

Our latest investigation report has identified that people with a learning disability, who have diabetes and administer insulin, have come to harm because of gaps in healthcare services and inequitab…
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Blog

Building a safer future for patients

5 August 2026

As we approach our third birthday and following publication of our latest annual report, HSSIB Chair, Dr Ted Baker, reflects on the difference our work has made for the safety of patients.
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News

HSSIB publishes second mental health PSIRF exemplar investigation

30 July 2026

HSSIB has published a new investigation report demonstrating how the Patient Safety Incident Response Framework (PSIRF) can be used to investigate patient safety incidents and identify opportunities …
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News

Annual report showcases HSSIB’s growing impact on patient safety

16 July 2026

Our third Annual Report and Accounts, published today, sets out our progress in strengthening patient safety across the NHS in England through independent investigation, learning and system-wide infl…
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News

Our response to the quality strategy for NHS-funded care in England

14 July 2026

The National Quality Board has published its quality strategy for NHS-funded care in England. The strategy provides a new structured approach to making quality the organising principle for all NHS ac…
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News

Our response to the Independent National Maternity and Neonatal Investigation

30 June 2026

We need a different approach to maternity safety in light of Baroness Amos’s report today. Too many women, babies and families are not getting safe healthcare and this urgently needs to change.
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News

Patients at risk as NHS and online prescriptions not joined up, report finds

25 June 2026

Patients who use online prescription services may be at risk of harm because the clinicians treating them do not have access to a complete picture of their health information.
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News

Our response to the Ockenden report

24 June 2026

Today, Donna Ockenden has published the findings of the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust. This is a significant moment for maternity safety, and o…
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Blog

Culture follows structure

19 June 2026

Ted Baker is a key speaker during Clinical Audit Awareness Week 2026. Ahead of his presentation, this blog explains why structural change must come before cultural change in patient safety, and the l…
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A stylised illustration of a healthcare pathway made up of connected circular icons in blue and green. The icons include a heart monitor, stethoscope, ambulance, pills, syringe, DNA strand, test tube and medical cross, all linked by a flowing line to represent joined-up care.
News

Patient safety risks across regional care pathways

18 June 2026

HSSIB has flagged patient safety risks across regional care pathways, warning that unclear roles, limited oversight and inconsistent information sharing can limit how risks are identified and managed…
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Blog

Do you see me?

15 June 2026

The theme for Learning Disability Week (15-21 June 2026) this year is ‘Do you see me?’: Senior Safety Investigator, Matt Mansbridge, reframes the question as a patient safety challenge to the whole h…
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Blog

Patient safety and diabetes

12 June 2026

During Diabetes Week, Craig Hadley (Senior Safety Investigator) shares learning from our insulin patient safety investigations. He highlights how a system-focused approach to safety in diabetes servi…
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Blog

HSSIB at Ergonomics & Human Factors 2026 conference

4 June 2026

The Health Services Safety Investigations Body (HSSIB) was represented by three of our safety investigation team at Ergonomics & Human Factors 2026, the annual conference of the Chartered Institu…
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Healthcare staff prepare and check medicines on a hospital ward using a drugs trolley, following a digital written record beside a patient’s bed.
News

NHS hospitals shouldering digital prescribing safety risks

28 May 2026

Our new report warns that 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 …
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News

Roundtable explores bias and discrimination in NHS patient safety investigations

20 May 2026

We've released a new briefing, in partnership with the NHS Race and Health Observatory (NHSRHO), to raise awareness and encourage positive change around bias and discrimination in patient safety…
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Person sitting on a patterned sofa at home, holding an insulin pen in both hands and checking it closely.
News

Life-threatening gaps in community support for people with disabilities managing insulin

19 May 2026

Our new report warns that people with diabetes and a disability may be left without the support they need to safely administer insulin at home – creating life-threatening risks.
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Blog

Safety and quality in healthcare: why the distinction is important

14 May 2026

In this blog, Ted Baker discusses a new paper by HSSIB colleagues and highlights the call for a fundamental rethink of how the NHS views and prioritises patient safety.
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News

What the King’s Speech means for HSSIB

13 May 2026

The King’s Speech has today set out the Government’s legislative agenda, including plans to bring forward legislation on the future of the Health Services Safety Investigations Body (HSSIB) and the w…
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Blog

Sharing HSSIB learning on mental health and patient safety

13 May 2026

During Mental Health Awareness Week, Philippa Styles (Director of Investigations at HSSIB) shares learning from our investigations, highlighting how a system-focused approach to safety in mental heal…
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News

Modelling PSIRF investigations in community mental health services

23 April 2026

We have published a new investigation demonstrating how mental health patient safety incidents can be examined under the NHS Patient Safety Incident Response Framework (PSIRF), using a case from comm…
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An image of a hospital waiting room with three empty seats and one seat occupied.
News

Legal gap leaves people in mental health crisis at risk in emergency departments

9 April 2026

Our latest report says that a significant legal gap puts patients in mental health crisis who attend the emergency department at risk and creates an impossible choice for staff trying to keep them sa…
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A male wheelchair user is unable to use an internal staircase for access to the next level.
News

Wheelchair users in prisons facing harm and dignity concerns due to inaccessible environments

2 April 2026

Our investigation highlights that wheelchair users and people with mobility issues in prisons are being put at risk of physical harm, psychological distress and avoidable dignity violations due to in…
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A healthcare assistant wearing blue scrubs checks the blood sugar level of a male patient.
News

Persistent risks to safe insulin care in hospitals

26 March 2026

Patients with diabetes who rely on insulin are facing persistent and serious safety risks when admitted to hospital, according to our latest investigation report.
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A female healthcare professional talks to a female safety investigator on a busy hospital ward.
News

New blueprint for healthcare investigators could save lives

3 March 2026

A first-of-its-kind framework has mapped the exact skills and qualities healthcare safety investigators need to prevent repeated harm to patients, offering a way forward from the old-style blame and …
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News

HSSIB publishes new strategy to strengthen investigation capability in England

26 February 2026

Today we launched our new strategy ‘Building Investigation Excellence’ to help meet the demands of a changing patient safety landscape.
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A young diabetic woman holds a syringe pen to inject insulin.
News

Disconnect in specialist diabetes care for adults with mental health problems

26 February 2026

Our new report urges action to improve access to specialist diabetes care for adults who self-administer insulin and live with a mental health problem, urging that gaps between services are putting v…
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Blog

Why I worry the NHS could slip backwards on patient safety

11 February 2026

Ted Baker, Chair of HSSIB, blogs about his concern that the NHS risks slipping backwards on patient safety and why this matters now.
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News

Our response to the NMC Spotlight report

5 February 2026

The Nursing and Midwifery Council (NMC) have published a Spotlight report informed by the first ever annual survey of professionals on their register, and data on where those on their register work …
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Blog

Making cancer care safer: what we’ve learnt from our investigations

4 February 2026

At the Health Services Safety Investigations Body (HSSIB), we’ve carried out seven patient safety investigations that have touched upon care for patients with cancer, to understand why issues occur a…
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News

Response to report that focuses on global collaboration to improve patient safety

30 January 2026

The Institute of Global Health Innovation at Imperial College London and Patient Safety Watch have published their annual State of Patient Safety report.
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A male nurse kneels next to a female patient laying in a bed on a hospital corridor.
News

Better understanding of the use of temporary care environments needed to minimise risks to patients

8 January 2026

Temporary care environments, commonly referred to as ‘corridor care,’ are being used across NHS trusts and there are widespread concerns about normalising their use and the impact on patients and sta…
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Head and shoulders photo of HSSIB Chair, Ted Baker, against a royal purple background. Text reads: New Year Honours List 2026.
News

HSSIB Chair awarded CBE in New Year Honours List

30 December 2025

Ted Baker, Chair of the Health Services Safety Investigations Body (HSSIB), has been named a Commander of the Order of the British Empire (CBE) in the New Year Honours List 2026 for services to healt…
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News

Ongoing risk of harm linked to electronic patient record systems

27 November 2025

Our latest report emphasises how electronic patient record (EPR) systems still contribute to patient care being missed, delayed or recorded incorrectly. This is despite national recommendations and a…
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A young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.
News

Report identifies risks in ambulance ECG interpretation and timely STEMI diagnosis

30 October 2025

Our latest report highlights the challenges faced by ambulance crews in interpreting ECGs when a patient has a suspected type of heart attack known as an ST Elevation Myocardial Infarction (STEMI).
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News

Our response to the Care Quality Commission’s State of Care 2024/25 report

24 October 2025

The State of Care report is the Care Quality Commission’s (CQC) annual assessment of the quality of health and social care in England.
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News

Our response to the NAO report on clinical negligence

17 October 2025

A new report from the National Audit Office (NAO) considers the cost of clinical negligence in England.
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News

Report highlights healthcare staff have welcomed shift under patient safety incident investigation framework

9 October 2025

Our latest report has found that NHS staff have been positive about the impact that the Patient Safety Incident Response Framework (PSIRF) can have on patient safety. However, it also reveals that mo…
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Close-up view of the back doors of an ambulance, against a grey sky. The blue emergency lights are switched on.
Blog

HSSIB impact: life-saving difference for acute aortic dissection patients

19 September 2025

To mark Global Aortic Dissection Awareness Day, Gareth Owens from the national patient charity blogs about the impact two HSSIB reports have had, with hundreds more people now receiving life-saving e…
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The logo for World Patient Safety Day 2025.
News

WHO calls for safe care for every newborn and every child

17 September 2025

Today – 17 September 2025 – is World Patient Safety Day. Led by the World Health Organization (WHO), it’s an opportunity to raise public awareness, foster collaboration between organisations and mobi…
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News

Report highlights importance of national response to maternity safety concerns

19 August 2025

Today, we published a new report and reiterates that challenges in maternity and neonatal safety are the result of systemic issues at a national level, rather than isolated issues within local areas.
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A female nurse gives an older woman medical pills.
News

Report emphasises importance of clear information to support safe and timely medication administration post hospital discharge

14 August 2025

We have published a report today highlighting the importance of sharing patient information between services effectively and ensuring patients are confident in medication self-administration before h…
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Aerial view of a prison site in the English countryside.
News

Report highlights IT and data sharing challenges affect safety of prison healthcare

24 July 2025

Our latest report has identified risks to patient safety due to poor interoperability between digital systems and challenges with GP registration processes in prisons.
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An image of a navy blue banner with the words Annual Report and Accounts 2024 slash 2025 it. The words Annual Report and Accounts is in white and the 2024 slash 25 is in yellow. There is also a teal coloured line underneath the wording
News

Second annual report marks a year of rapid progress and driving impact in patient safety

23 July 2025

Our second Annual Report and Accounts has been published, highlighting a full year of investigation, learning and transformation.
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A district nurse cares for an elderly man with a head injury in his living room at home.
News

Investigation finds patients suffer harm as electronic communications fail to support their safe discharge from hospital

10 July 2025

Patients are coming to harm due to failures in the way critical clinical information is electronically communicated when they are discharged from hospital.
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