Patient safety investigations

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A person in bed sits beside a healthcare worker holding a weekly medication organiser. The person places a hand on their chest while the healthcare worker appears to discuss their medicines in a care home setting.

Medication safety in care homes for older people

These local investigations explore how medication is managed in everyday practice, while recognising that care homes are people's homes and should support residents' choices, preferences and independence.
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Launched

  • Theme:

    Medication, Communication and decision making, Continuity of care
Person sitting indoors with hands clasped under their chin, looking downward in a quiet home setting.

Preventing perinatal mental health deaths: recognition, access and support

We have launched an investigation into deaths associated with perinatal mental health concerns. The investigation will examine how serious mental health concerns are identified and risk is assessed, how women access care pathways, and what support is available to them.
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Launched

  • Theme:

    Mental health, Maternity, Access to care
A surgical team wearing protective gowns, masks and caps performs an operation in a hospital operating theatre. Medical staff work around the patient under surgical lighting, with monitoring equipment visible in the background.

Improving surgical safety through reporting, monitoring and learning

This investigation will focus on current monitoring systems and how the information they collect is shared and effectively used to help identify potential issues and drive improvements in surgical safety.
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Launched

  • Theme:

    Acute, Hospital care, Surgical
Close-up of an ultrasound scan being performed on a pregnant person's abdomen in a clinical setting, with the ultrasound probe held against the skin and medical equipment visible in the background.

Placenta Accreta Spectrum: understanding the barriers to timely diagnosis and care

Placenta Accreta Spectrum (PAS) is a life-threatening complication of pregnancy where the placenta abnormally attaches, or grows into, the muscle wall of the womb. This makes delivery of the placenta at the time of birth very difficult. PAS can result in massive blood loss and is a cause of materna…
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Launched

  • Theme:

    Delayed diagnosis, Maternity, Medical tests
An image of a hospital waiting room with three empty seats and one seat occupied.

Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

published
Mental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who come into contact with urgent and emergen…
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Published

  • Theme:

    Mental health, Emergency care, Access to care

  • Awaiting safety recommendation responses

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

Electronic patient record systems – electronic referrals for ongoing care

published
We have launched an investigation that explores risks to patient safety where electronic patient record (EPR) systems, introduced to support referrals for patient care, have contributed to harm from missed or delayed care.
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Launched

  • Theme:

    Access to care, Follow-up care, Continuity of care
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
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