Patient safety investigations

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Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

published
We are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family
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Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

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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Launched

  • Theme:

    Mental health, Emergency care, Access to care

  • Awaiting safety recommendation responses

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An exploratory review of maternity and neonatal services

published
This report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Health…
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Published

  • Theme:

    Maternity investigations, Neonatal
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Online prescribing: challenges and opportunities to improve patient safety

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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Launched

  • Theme:

    Medication
A district nurse cares for an elderly man with a head injury in his living room at home.

Workforce and patient safety

published
The workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. These investigations consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Published

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

Focus on the hand of a hospital patient laying on a bed. An IV cannula is inserted in a vein on the top of their hand.

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

published
Three reports that model investigation of sepsis under the Patient Safety Incident Response Framework (PSIRF), to boost local learning and help improve investigation quality in the NHS.
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Published

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
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Mental health inpatient settings

published
This series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. We've completed five investigations and an overarching report that explores cross-cutting patient safety risks.
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Published

  • Theme:

    Mental health

  • Awaiting safety recommendation responses

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The impact of staff fatigue on patient safety

published
Staff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes…
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Published

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

A young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.

12-lead electrocardiograms (ECGs) in ambulance services

published
These two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Published

  • Theme:

    Emergency care, Cardiac

  • Awaiting safety recommendation responses

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Safety management

published
This investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
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Published

  • Theme:

    NHS staff, Patient safety themes, Patient and family, Continuity of care

  • Awaiting safety recommendation responses

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