Safety accountability and oversight thematic review

We have launched a thematic review of Healthcare Safety Investigation Branch (HSIB) and Health Services Safety Investigations Body (HSSIB) investigation reports, covering the period April 2017 to April 2026, that explores patient safety accountability and oversight.

We have undertaken work in this area previously, such as exploring ‘Safety management’ and ‘Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare’. This thematic review is intended to bring together collective learning across all our reports.

Through HSSIB’s internal review processes, it was identified that many of our reports explore safety accountability and oversight and include associated safety recommendations.

Initial analysis suggests that the patient groups that feel the greatest impact of lack of safety accountability and oversight are patients with complex and/or long-term conditions and needs, vulnerable patients and patients who are unable to advocate for themselves.

The systemic accountability factors identified during this analysis relate to patient safety concerns including issues with effective information sharing, delays to diagnosis and treatment when transitioning between services, learning from safety incidents not being shared, known local safety concerns not being escalated and responded to at a regional and national level and a lack of clarity in relation to roles and responsibilities. HSSIB has made numerous recommendations across many reports which highlight the gaps at local, regional and national level where accountability has impacted on the management of systemic safety issues.

This review will consider safety accountability and oversight across all HSIB and HSSIB investigations to date. It provides an opportunity to identify which patient groups are most affected by lack of accountability and oversight, share collective learning and potentially consolidate safety recommendations relating to accountability and oversight.

The review has the following terms of reference:

• To thematically analyse HSIB/HSSIB investigation reports for safety accountability and responsibility across the health and care sector, with a focus on how they impact on people with complex needs, long-term health conditions and/or who are not able to advocate for themselves.
• To thematically analyse HSIB/HSSIB safety findings, recommendations and observations for safety accountability and responsibility across the health and care sector, with a focus on how they impact on people with complex needs, long-term health conditions and/or who are not able to advocate for themselves.
• To clarify the terminology of safety accountability and responsibility across the health and care sector.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about this work before we publish the final report, please email investigations@hssib.org.uk.