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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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Empty chairs outside double doors leading to an outpatients department in an NHS hospital.
News

Dignity fears contribute to prisoners not attending hospital or clinic appointments

28 November 2024

Our latest report raises concerns over female prisoners privacy and dignity after an investigation found they are often taken to outpatient appointments by male prison officers.
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Silhouette of a man sitting on the edge of a bed, facing away towards a large, bright window.
News

Harm caused by mental health out of area placements

21 November 2024

Patients experience harm with the continued use of ‘inappropriate’ out of area placements for their mental health inpatient care, says our latest report.
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News

HSSIB stops posting on X

18 November 2024

We have been reviewing the use of our social media channels and have taken the decision to stop posting updates on X from today.
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A map of Australia with the Australian flag pinned to it.
Blog

How HSSIB contributes to patient safety: a view from Australia

4 November 2024

Professor Peter Hibbert from the Australian Institute of Health Innovation reflects on how HSSIB contributes to improved patient safety, plus our education offering and areas for improvement.
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News

Our response to the Care Quality Commission State of Care report 2023/24

25 October 2024

Following the publication of the State of Care report, HSSIB’s Chief Executive, Dr Rosie Benneyworth says:
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A blurred hospital corridor with bright ceiling lights.
News

Report emphasises importance of therapeutic care in mental health units and wards

24 October 2024

We have published the first of our investigations into mental health inpatient settings and make recommendations to ensure that therapeutic care is a priority.
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News

Our response to the Dash Review

15 October 2024

Review of patient safety across the health and care landscape.
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A male investigator at work in an office, using a desktop computer.
Blog

The investigator’s toolkit: FRAM

9 October 2024

David Fassam, Senior Safety Investigator, continues our series of blogs that take a look at the methods we use in our patient safety investigations. Next up is the Functional Resonance Analysis Metho…
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News

Our response to the Lord Darzi Review

12 September 2024

Following the publication of Lord Darzi’s Independent Investigation into the NHS in England, HSSIB’s Chief Executive, Dr Rosie Benneyworth says:
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A female British Asian healthcare worker makes a hospital bed.
News

Discrimination stops temporary workers speaking up about safety concerns

5 September 2024

Our latest investigation report reveals there is widespread discrimination against temporary staff in the NHS and this creates a culture of fear that stops them speaking up about patient safety.
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Aerial view of a prison site in the English countryside.
News

Unnecessary 999 calls from prisons lead to a ‘significant’ loss in ambulance crew time

29 August 2024

Ambulance crews spend significant time diverting resources to 999 callouts in prisons that are cancelled or not a serious enough medical emergency, says our latest report.
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An older man wearing glasses sits using a laptop.
News

Patient and staff concerns over GP online consultation tools

25 July 2024

Our latest report says that patient safety must be prioritised as online consultation tools in general practice continue to be implemented.
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Annual report 2023-24 cover
News

Annual report sets out progress in our first six months

22 July 2024

Our first annual report and accounts, published today, covers the six months from our launch to 31 March 2024 and sets out our priorities as a new organisation, with achievements and progress to date.
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A young girl with an unhappy look on her face lies on her side in a hospital bed, hugging her teddy.
News

Safer mental health environment needed in paediatric wards

23 May 2024

Our latest report has called for improvements and changes in the design of paediatric wards to ensure they provide a therapeutic environment.
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A sad looking woman lies awake on a hospital bed.
News

Self-harm risk of patients under continuous observation in hospital wards

9 May 2024

Our latest investigation has found ‘limited evidence’ that the current approach to continuous observation of adult patients at risk of self-harm when on hospitals wards is effective.
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A man packs supplies into crates at a food bank.
Blog

Tackling health inequity: observations from an investigation visit

30 April 2024

Nichola Crust, Senior Safety Investigator, shares how one primary care network in the north of England is tackling health inequity by building relationships beyond traditional healthcare boundaries, …
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A nurse wearing scrubs prepares surgical instruments including swabs.
News

Risk of surgical swabs being left inside patients

16 April 2024

We've investigated the risk of unintentional ‘retained’ swabs after invasive procedures. The investigation was launched after we examined the case of a patient who had two swabs left in her ches…
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A tired hospital doctor rests his head on his hand as he sits at a desk.
News

Share your experience of healthcare staff fatigue

26 March 2024

We’ve just launched an investigation to look at fatigue risk in healthcare and its impact on patient safety.
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Healthcare professionals in a busy hospital corridor.
News

Temporary NHS staff a ‘lost voice’ in crucial patient safety investigations

14 March 2024

Our latest investigation has found that not involving temporary NHS staff in serious incident investigations may ‘undermine’ its ability to improve patient safety.
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A surgical team wearing blue scrubs perform an operation in a hospital theatre.
Blog

Elective care recovery: taking a systems approach

5 March 2024

Senior Safety Investigator, Neil Alexander, blogs about the challenges facing the NHS in tackling the elective care backlog and how learning from our investigation reports may be able to help the NHS…
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A male patient's hand rests on a nurse call button in a hospital bed
News

New learning report brings together learning on patient misidentification

8 February 2024

Our latest report reiterates that the misidentification of patients remains a persistent safety risk across the NHS but is one that is under-recognised and under-researched.
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An anaesthetist performs a nasotracheal intubation of a child.
News

New report charts safety risks associated with managing patients with known ‘difficult airways’ in emergency situations

25 January 2024

Our latest report shows improvement is needed at a national level in the communication, preparation and planning for patients who may have ‘a difficult airway’ – that is the anatomy of their mouth, t…
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An illustration showing the many parts that make up the healthcare system, including healthcare staff, diagnostics, medication and different services like emergency care.
Blog

The investigator's toolkit: SEIPS

17 January 2024

Continuing our series of blogs that look at the range of investigation methods we use, Deinniol Owens and Dr Helen Vosper highlight how SEIPS can be the investigator’s ‘swiss army knife’ when plannin…
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200 guests sit watching panel speakers in a large hall.
News

Reflecting on three months as HSSIB

21 December 2023

This week marks three months since an event was held at Kings College London to formally recognise our formal establishment as the Health Services Safety Investigations Body (HSSIB).
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A female pharmacist stands behind a pharmacy counter using a desktop computer. Medicines line the shelves behind her.
Blog

Electronic patient record systems: recurring themes arising from safety investigations

19 December 2023

Senior Safety Investigator, Helen Jones, blogs about some of the key benefits and risks of electronic patient record (EPR) systems used in healthcare, sharing what we are learning from our safety inv…
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An older male patient talks to a GP, sat either side of a desk in a consulting room.
News

Change needed in how GP continuity of care is prioritised at a national level

30 November 2023

Making continuity of care an ‘essential requirement’ for GP practices could reduce the risk of a delay in diagnosing serious health conditions, and ease significant pressure on GP’s workload and welf…
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A nurse speaks to a cancer patient.
News

Investigation explores risk of patients not receiving crucial medication through a portable medical device

14 November 2023

Alarms on a portable medical device may not notify staff that medication is not being delivered as it should, creating a ‘hazardous situation’ and increasing the risk of harm to patients.
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A nurse helps an older male patient to stand up from his hospital bed.
News

New report shows needs of learning disability patients ‘not consistently met’ when they are in hospital

2 November 2023

Despite national efforts to address inequity, the health and care system is not always meeting the needs of people with a learning disability when they are cared for in hospital, says our latest repo…
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A middle aged woman gazes out of a window.
Blog

The impact of menopause on mental health

30 October 2023

Amber Sargent and Helen Jones blog about the patient safety issues that arise when the impact of menopause on mental health is not considered during clinical assessments.
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News

Our response to the Care Quality Commission State of Care report 2022/23

20 October 2023

State of Care is the annual assessment of healthcare and social care in England by the Care Quality Commission (CQC).
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200 guests sit watching panel speakers in a large hall.
News

HSSIB officially launches with aim to drive radical change in patient safety

18 October 2023

As our newly formed investigation body officially launched today, clear messages came from our leadership team that we will aim to drive ‘radical’ change in how patient safety is managed across healt…
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A space shuttle launches into a blue sky.
News

Report explores ‘proactive and integrated approach’ to managing safety in healthcare

18 October 2023

Today we publish our first report as the Health Services Safety Investigations Body, exploring the use of safety management systems and how they could contribute to more effective safety management i…
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Back view of a female employee speaking on a video call with diverse team of colleagues.
News

Philippa Styles appointed as Director of Investigations

16 October 2023

Philippa Styles will join our team shortly as Director of Investigations. This is a critical role within the leadership team, overseeing all investigations undertaken by the Health Services Safety In…
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Close up of the gloved hands of a laboratory assistant as they carry out blood tests.
HSIB legacy content
Blog

The importance of non-patient facing NHS services in patient safety

19 July 2023

Senior Safety Investigators Russell Evans and Craig Hadley highlight how behind-the-scenes services are crucial to help the NHS operate effectively and safely, in our latest blog.
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A healthcare professional looks at notes at the hospital bedside of a patient lying on a bed behind them.
HSIB legacy content
Blog

Helping NHS staff to do their jobs: design of information in the workplace

29 June 2023

Senior Safety Investigators Clare Crowley and Nick Woodier blog about the simple but often overlooked measures that NHS staff and organisations can take to improve the design and display of informati…
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Three colleagues engage in an animated conversation in an open plan office space.
HSIB legacy content
Blog

The investigator's toolkit: Using Appreciative Inquiry in safety investigations

5 June 2023

In the first in a series of blogs looking at the range of investigation methods we use, Nichola Crust reflects on how Appreciative Inquiry can be used to examine patient safety and identify opportuni…
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A Norwegian ambulance drives with it's blue lights flashing along a road in Oslo.
HSIB legacy content
Blog

Building an international network for patient safety investigation

4 May 2023

Our Chief Investigator, Rosie Benneyworth, writes about exciting developments in the world of international patient safety investigation.
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A female clinician sits at a desk using a desktop computer.
HSIB legacy content
Blog

Failing to communicate: challenges with electronic communication systems

18 April 2023

Matt Mansbridge and Melanie Ottewill blog about the patient safety issues that arise when systems are unable to communicate with each other, as highlighted in three of our national investigations to …
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A tired surgeon sits on the floor of a hospital corridor with their head hanging down.
HSIB legacy content
Events

The impact of staff fatigue on patient safety: how do we manage the risk

17 March 2023

We facilitated a half-day event on 17 March 2023 to ask how healthcare can understand and start to manage the risk of staff fatigue.
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A Black male healthcare professional sits outside in front of a brick wall, drinking a coffee.
HSIB legacy content
Blog

Starting the conversation around NHS staff fatigue and patient safety

8 March 2023

Laura Pickup blogs about NHS staff fatigue in the run up to World Sleep Day and our fatigue event on 17 March 2023.
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A member of intensive care staff wearing a face mask stands in front of an artificial lung ventilation monitor.
HSIB legacy content
Blog

The importance of equipment design in patient safety

10 January 2023

Laura Pickup blogs about equipment design in healthcare and asks whether NHS staff should be held accountable for the use of devices and equipment leading to patient safety events.
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People and healthcare staff look busy in a non-clinical area of a hospital ward.
HSIB legacy content
Blog

New opportunities for risk management

10 January 2023

Jonathan Back, Analyst, blogs about the opportunities the healthcare system has to adopt a proactive risk management approach to improve patient safety.
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Empty beds on a hospital ward looking out onto a green, landscaped courtyard garden.
HSIB legacy content
Blog

The impact of reorganising NHS services on patient safety

5 January 2023

Scott Hislop, Deputy Director of Investigations, looks at the challenges faced by the NHS when flexing to meet demands and how to mitigate potential risks to patient safety.
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A group of NHS doctors and nurses stand together on a hospital ward, talking and smiling .
HSIB legacy content
Blog

Supporting NHS staff involved in patient safety investigations

19 December 2022

In this blog, Matthew Wain highlights how NHS organisations can support staff with patient safety investigations, and more generally, in the face of increased pressure.
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Female doctor speaks to a male patient propped up on a hospital bed with two relatives sat at his bedside.
HSIB legacy content
Blog

Maintaining family involvement in the face of winter pressures

6 December 2022

Louise Pye highlights how the Patient Safety Incident Response Framework can help NHS trusts involve patients and families in the face of extreme winter pressures.
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A doctor walks down a hospital corridor, the background and the doctor are blurred.
HSIB legacy content
Blog

Bill Kirkup speaks to HSIB staff about 'Reading the signals'

17 November 2022

Our Clinical Director of Maternity Investigations shares the details of a seminar delivered to HSIB staff by Dr Bill Kirkup CBE as part of our investigation education programme.
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A doctor wearing a stethoscope around their neck holds an iPad.
HSIB legacy content
Blog

PSIRF and the HSIB: supporting how the NHS responds to patient safety incidents

9 November 2022

In this blog Melanie Ottewill explains how our work is supporting the NHS to adopt a systems approach to local safety investigations through the Patient Safety Incident Response Framework (PSIRF).
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Illustration of a man holding a giant pencil in front of an oversized calendar and alarm clock. He points at a gold star circled on the calendar.
HSIB legacy content
Blog

100 days at HSIB

9 November 2022

Dr Rosie Benneyworth reflects on her first 100 days leading HSIB as interim Chief Investigator.
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