Reflecting on a period of growth, the report captures achievements from 1 April 2024 to 31 March 2025. It demonstrates our impact in uncovering critical patient safety issues and influencing change across the healthcare system.
Over the past year we have made significant strides in strengthening safety through independent investigations, with a commitment to learning and a focus on being a strong and inclusive voice across the healthcare system. Our performance is assessed against five strategic themes, reflecting what we have specifically embedded to deliver high-quality meaningful work.
Our Annual Report comes shortly after the NHS 10 Year Plan and the Dash Review into Patient Safety were published. HSSIB will move into the CQC as a discrete unit in the future. The 10 Year Plan recognised HSSIB as a centre of excellence for investigations and we will continue with our focus on proactive and independent safety investigations.
Key achievements under the five themes include:
Investigations that have impact
From mental health and medication safety to digital tools and prison healthcare, our investigations tackled some of the most pressing patient safety issues. Public and stakeholder consultation helped us to re-shape our investigation criteria ensuring our approach remained transparent, robust and grounded in the patient safety concerns that really affect people. By working closely with stakeholders, whilst maintaining independence, our safety recommendations are informed and actionable. .
Putting people at the heart
We’ve placed patients, families and staff at the heart of what we do. Their lived experiences were central to our investigations—especially in mental health—and shaped key recommendations. A new partnership with the Patients Association is helping us identify future areas of focus directly informed by public concerns. We also addressed staff wellbeing and opened up critical discussions, including those on sexual safety and fatigue.
Being a strong and inclusive voice across the system
This year, our Chief Executive led national work to strengthen the quality of safety recommendations across the NHS—work that’s already influencing wider improvement. Our team has been active across the healthcare landscape, sharing expertise through events, publications, research and media, ensuring our voice remains strong and influential in shaping patient safety policy and practice.
Building professional investigation expertise
Our education programme continues to grow, helping NHS staff develop the skills needed for professional, effective safety investigations. We launched fee-funded courses to widen access and introduced specialist training for advanced learners. A successful student placement pilot and ongoing international collaboration are helping shape the next generation of safety experts.
A culture of compassion and inclusion
Internally, we’ve built a stronger, more inclusive organisation. A clear governance framework, shared values, and our commitment to equality, diversity and inclusion underpin how we work. Staff wellbeing remains a top priority, supported through targeted initiatives and regular feedback.
Ted Baker, Chair of HSSIB says: “As we continue into HSSIB’s second year, we are having a visible impact on patient safety as you will find highlighted throughout this report – there are many case studies and excerpts which clearly show the strides we have made. Our influence and stature as an independent body has grown and our voice on patient safety issues is strong and respected.
“Ultimately successful management of safety fosters a system wide commitment to prioritise safety. Our existence as an independent, expert body is an essential part of the system and we must consistently reinforce this message. Too often, experience shows us the tragic consequences when warnings are not heeded, and recommendations not implemented. Our role is not only to investigate but to highlight opportunities to prevent future harm, even – and especially – when doing so is difficult.”
Dr Rosie Benneyworth, Interim Chief Executive says: “I feel immensely proud of what we’ve achieved in the last year. Across HSSIB, we have continued to demonstrate the power of listening, learning and acting with integrity to drive meaningful change in healthcare. Through our investigations, education programmes and steadfast commitment to patient safety, we’ve had a direct and lasting impact on the lives of patients across England and beyond.
“What stands out most to me is the way our teams – whether conducting detailed investigations, supporting patients and families or delivering crucial support services – have worked with such professionalism, compassion and dedication. We haven’t shied away from challenging conversations or complex issues because we recognise that each insight and lesson will contribute to ongoing efforts to improve patient safety.”
Highlights and achievements in numbers
Between 1 April 2024 and 31 March 2025
- 19 investigation reports published.
- We made 310 safety recommendations to 61 organisations to influence improvement.
- 14,427 new students registered across all our education courses
- An example of our patient and family engagement - we spoke to over 100 patients and families during out mental health inpatient investigations.
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