Our work should ultimately be judged not by the number of reports we publish or recommendations we make, but by whether our work contributes to safer care. This is a demanding question to answer. Healthcare is a complex system, change is rarely attributable to a single organisation, and improvements in safety outcomes can take years to become measurable.
We should therefore be cautious, but almost three years after the Health Services safety Investigations Body (HSSIB) became an independent statutory body, there is now a growing body of evidence that our work is making a difference.
From recommendations to real change
Since 1 April 2024, HSSIB has made 56 safety recommendations. Everyone has received a formal response from the recipient organisation setting out the actions it will take, with those actions underway. Eleven recommendations made by HSIB/HSSIB have been fully implemented and closed, while we continue to monitor the remainder of which 30 have actions underway. During 2025/26, we published 16 investigations, delivered every published investigation within its planned timescale and followed up 100% of safety recommendations within agreed timeframes.
Activity is not the same as impact. The more important question is what has changed as a result. Perhaps our most powerful example is the work on acute aortic dissection, which began under our predecessor organisation, HSIB. An investigation into the death of a 50-year-old man contributed to the first joint national guidance on diagnosing thoracic aortic dissection from the Royal College of Emergency Medicine and the Royal College of Radiologists. It also contributed to the inclusion of ‘aortic pain’ in the Manchester Triage System and helped reinforce the THINK AORTA campaign.
National audit data subsequently showed an 82% increase in emergency aortic surgery over ten years, equivalent to more than 300 additional patients each year accessing potentially life-saving treatment. This reflects the combined efforts of clinicians, professional bodies, patient campaigners and others. But there is good evidence that our independent safety investigation played an important part in bringing about change.
Our work on the detection of jaundice in newborn babies provides another example. Our investigation resulted in a change to NICE guidance, but we wanted to understand whether that change was reaching patients. Our subsequent impact evaluation found that, at one trust, an automatic laboratory process introduced as part of the new approach had detected abnormal results in 72 babies before clinicians had requested a jaundice test.
That is the kind of evidence we increasingly need to seek. It is not enough for a recommendation to be accepted or a policy to be rewritten. We need, wherever possible, to understand whether change has reached the front line and made care safer.
Across our work there are many other examples. Investigations have contributed to a national competency-based training programme for X-ray interpretation in nasogastric tube placement; national research and a NICE technology review on preventing retained swabs; an app enabling patients to carry information about the management of a difficult airway; and a national competency framework for staff working in sterile services and decontamination departments.
Taken together, these changes demonstrate a consistent pattern of investigation leading to changes in guidance, technology, training and clinical practice.
Changing the system
Some of our most significant impacts reach beyond individual clinical pathways. Our investigation into out-of-area mental health placements directly influenced the Mental Health Act 2025, strengthening the consideration given to the wishes and preferences of patients, families and carers. The GP contract was amended to include continuity of care as an explicit requirement following an investigation into continuity of care in general practice. Other investigations have contributed to national guidance on implementing the Mental Capacity Act for adults with learning disabilities, guidance on staying safe from suicide, collaborative work with families on non-anchored ligature risks, and work to improve national guidance on the design of paediatric ward environments.
Our reach also extends beyond conventional NHS settings. Following investigations into healthcare in prisons, His Majesty’s Prison and Probation Service and the Association of Ambulance Chief Executives established formal communication routes between prisons and ambulance services across the country for the first time. Emergency cards carried by prison officers were also redesigned to provide clearer guidance on when a 999 call is required.
These examples demonstrate one of the strengths of independent national safety investigation. Many of the greatest risks to patients do not sit neatly within a single organisation. They arise at the boundaries between services, organisations and sectors, where responsibility may be dispersed and no one organisation has a complete view of the system. Patients do not experience care in organisational silos. Neither should our understanding of safety.
Making hidden risks visible
Not all patient safety impact can be measured through completed recommendations. Sometimes the most important contribution of an investigation is to make a poorly understood risk visible and change the way the system thinks about it.
Our work on staff fatigue is one example. Fatigue is familiar to almost everyone working in healthcare, but it has often been regarded principally as an issue of individual wellbeing rather than as a system-level risk to patients. Our investigation helped to reframe fatigue as a patient safety issue requiring organisational and national attention.
Our investigation into temporary care environments, commonly described as corridor care, similarly examined a highly visible problem through a systems lens. It explored how capacity constraints, patient flow, workforce pressures and the normalisation of workarounds combine to create environments in which patients and staff are exposed to risk. We used an accelerated investigation model to provide timely learning during a period of intense operational pressure, showing that national investigation can be both rigorous and responsive.
Digital safety is another increasingly important area. Our work on electronic patient records and discharge communications has shown that digital safety is not simply a matter of whether the technology works as intended. It depends on procurement, implementation, interoperability, clinical workflow and how people interact with digital systems in the realities of everyday care.
This will become increasingly important as artificial intelligence is deployed across healthcare. AI has enormous potential, but it will also create new forms of risk. These risks cannot be understood by examining algorithms in isolation. We will need to investigate the entire sociotechnical system, how technology is procured, implemented and monitored; how clinicians interact with it; how automation changes human behaviour; and how weak signals of emerging harm can be identified before they become widespread. This is precisely the kind of challenge for which systems-based safety investigation is needed.
Building investigation excellence
Perhaps HSSIB’s greatest long-term impact will come not from the investigations we conduct ourselves, but from helping to improve the quality of investigation across healthcare.
There is no shortage of investigations in the NHS. But too many still rely on relatively superficial approaches that identify a failure to follow a procedure and then recommend retraining, a new policy or a reminder to staff. Such responses can provide reassurance without addressing the conditions that made harm possible.
Our Building Investigation Excellence strategy is intended to help change this. Our educational materials are embedded within the National Patient Safety Syllabus, our human factors course has professional accreditation, and our investigation tools are freely available to the healthcare system.
We have also used exemplar investigations under the Patient Safety Incident Response Framework to demonstrate what good systems-based investigation looks like in practice. Our collaboration with the University of Reading has produced a framework identifying 38 competencies required for effective safety investigation, an important step towards treating investigation as a professional discipline rather than simply an administrative response after something has gone wrong.
The potential multiplier effect is considerable. HSSIB can undertake only a limited number of national investigations itself. But if our expertise can help improve the quality of thousands of investigations across healthcare, the impact could extend much further.
Why our model matters
Healthcare has traditionally struggled to distinguish between different purposes of investigation. Some investigations seek to determine accountability. Others provide assurance. Learning investigations ask a different question, why did the system behave as it did, and what needs to change to reduce the risk of recurrence?
All these purposes are legitimate, but they are not interchangeable. An investigation designed primarily to identify individual responsibility will inevitably affect what people are prepared to disclose. A learning investigation requires different conditions.
For HSSIB, two conditions are fundamental, independence and safe space.
Independence allows us to follow evidence wherever it leads, to investigate across organisational boundaries, to challenge established assumptions and to examine system design without pressure to defend existing arrangements.
Safe space enables staff to provide candid evidence for the purpose of learning, protected from its subsequent use to determine blame or liability. If people cannot speak openly about how work is really done, including the compromises, workarounds and pressures influencing their decisions, investigations risk reaching superficial conclusions and learning the wrong lessons.
Independence and safe space are therefore not privileges for HSSIB or protections for healthcare professionals at the expense of patients and families. They are essential parts of the framework required for effective learning.
The next stage must be more ambitious
We can be positive about HSSIB’s achievements but there is no room for complacency. Forty-five of our 56 recommendations remain in implementation. Complex system changes can take years to become fully embedded. Attribution remains difficult, and we must continue strengthening our ability to evaluate whether our work leads to changes in practice and, ultimately, safer care.
One priority for the future should therefore be to make impact evaluation as rigorous as investigation itself. Our work on neonatal jaundice provides a model: following recommendations beyond formal acceptance, through policy change and implementation, to their effects at the front line.
We must also become increasingly proactive. Traditional safety investigation begins after harm has occurred. Modern safety science requires us to do more, to identify weak signals, understand emerging risks and examine the conditions that make future harm more likely. Our rapid-response work, our focus on safety management systems and our developing work on AI safety point towards a future in which investigation contributes not only to learning from yesterday’s incidents, but to anticipating tomorrow’s risks.
Our educational role also has considerable potential. The development of investigator competencies creates an opportunity for greater consistency in the standards of safety investigation. HSSIB can continue to develop as a centre of excellence, helping the NHS move beyond variable local approaches towards investigation as a genuinely professional, systems-based discipline.
From learning after harm to managing safety
The strongest case for HSSIB is not that every recommendation has transformed care, nor that an investigation body can solve the NHS’s patient safety challenges by itself. The case is that a relatively small organisation without enforcement powers has already contributed to changes in clinical guidance, professional training, technology, national contracts, prison procedures and primary legislation. Our investigations have contributed to measurable improvements in care, exposed risks that might otherwise have remained poorly understood, and begun to build stronger investigative capability across healthcare.
The NHS needs to move beyond a model of safety that relies predominantly on investigating incidents after patients have been harmed. We need better mechanisms for identifying emerging risks, understanding safety across organisational boundaries, learning from everyday work and managing hazards before they result in serious harm.
HSSIB has the expertise and statutory framework to make an important contribution to that transition. The task ahead is to build on what we have achieved, stronger evaluation of impact, greater investigative agility, deeper expertise in emerging risks such as AI and digital healthcare, wider professionalisation of safety investigation, and a more proactive approach to understanding how risk is created and managed across the health system.
Our Annual Report provides evidence of real progress, but it should also be a platform for greater ambition. HSSIB’s greatest potential lies not simply in investigating why patients were harmed yesterday, but in helping the healthcare system understand and manage the risks that could harm them tomorrow.
