Patient safety investigations

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A young diabetic woman holds a syringe pen to inject insulin.

Insulin: supporting safe self-administration in vulnerable patient groups in the community

published
This series of reports explores risks to patient safety for patients in the community who self-administer insulin and who may be at increased risk of harm because of their circumstances.
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Published

  • Theme:

    Mental health, Medication, Learning disabilities

  • Awaiting safety recommendation responses

Person using a smartphone beside a laptop, overlaid with digital graphics representing artificial intelligence, including a microphone labelled “AI”, audio waveforms, voice messages, speech-to-text symbols and communication icons. The image illustrates AI-powered voice and language technology.

The use of Ambient Voice Technology in hospitals

Adoption of Ambient Voice Technology (AVT) is accelerating while the safety implications are not fully understood. This investigation will focus on acute adult secondary care settings to understand how AVT may contribute to patient harm, associated patient safety risks and accountability.
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Launched

  • Theme:

    Acute, Hospital care, Medical devices
Child reaches towards a glowing bubble tube in a sensory room, illuminated by pink and purple lights. The tube is filled with rising bubbles and glowing beads, casting coloured light across the scene.

Care of children waiting for access to child health community services

There is widespread concern about child health community services presenting some of the longest waits in the healthcare system and these delays contributing to lasting harm where interventions are critical to healthy childhood development.
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Launched

  • Theme:

    Delayed diagnosis, Long-term conditions, Access to care
Young woman wearing a baggy long sleeve jumper meets with her doctor.

Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)

published
These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). Currently, two of three investigation reports has been published.
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Launched

  • Theme:

    Mental health, Hospital care, Patient safety themes
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.

Deterioration in adults with a learning disability in primary care

We have launched an investigation that explores the care adults with a learning disability receive in primary care when their health is deteriorating or they have new symptoms.
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Launched

  • Theme:

    Delayed diagnosis, Access to care, Learning disabilities
A healthcare professional sits in a consulting room speaking with a young person seated opposite. A desk, computer screens and office equipment are visible in the background.

Identifying and supporting mental health problems in children via general practice

We have launched an investigation exploring how mental health problems in children are identified and supported via general practice. This is due to widespread concern that there are limitations and wide variation in early identification and intervention for children with mental health problems.
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Launched

  • Theme:

    Mental health, Primary care, Patient and family
Older person in bed at home holding a mug and speaking with a carer seated beside the bed, with a bedside lamp and wooden headboard in the background.

Safety accountability and oversight thematic review

We have launched a thematic review of HSIB and HSSIB investigation reports, covering the period April 2017 to April 2026, that explores patient safety accountability and oversight.
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Launched

  • Theme:

    Long-term conditions, Patient safety themes, Continuity of care
Close up of hands using a smart phone.

Online prescribing: challenges and opportunities to improve patient safety

published
This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
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Published

  • Theme:

    Medication

  • Awaiting safety recommendation responses

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.

Patient safety across regional care pathways: learning from an HSSIB investigation pilot

published
We've identified patient safety risks across regional care pathways, linked to unclear roles, limited oversight and inconsistent information sharing which can limit how risks are identified and managed across NHS organisations.
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Published

  • Theme:

    Communication and decision making, Access to care, Continuity of care
A female nurse gives an older woman medical pills.

Medication related harm

published
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We have completed three local investigations and a national investigation that look at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care

  • Awaiting safety recommendation responses

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