Patient safety investigations

Start date:

Report publication date:

Clear All
Get updates via RSS feed
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

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…
Read the summary
Launched

  • Theme:

    Mental health, Emergency care, Access to care

  • Awaiting safety recommendation responses

Image shows a pregnant person holding palms in a heart shape

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…
Read the summary
Published

  • Theme:

    Maternity investigations, Neonatal
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 is underway, looking at medication related harm.
Read the summary
Published

  • Theme:

    Medication, Communication and decision making, Continuity of care
Close up of hands using a smart phone.

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.
Read the summary
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.
Read the summary
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.
Read the summary
Published

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
A blurred hospital corridor with bright ceiling lights.

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.
Read the summary
Published

  • Theme:

    Mental health

  • Awaiting safety recommendation responses

A young burnt out doctor sits resting his chin on his hands.

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…
Read the summary
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).
Read the summary
Published

  • Theme:

    Emergency care, Cardiac

  • Awaiting safety recommendation responses

A smiling health visitor wearing green scrubs helps an older woman to walk in her home.

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.
Read the summary
Published

  • Theme:

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

  • Awaiting safety recommendation responses

« First Previous
Page 2 of 12
Next Last »