Healthcare Safety Investigation Branch
Corporate/Government Newsroom
We are dedicated to improving patient safety through independent investigations into NHS-funded care across England.
Our investigations focus on systems and processes in healthcare. We identify the factors that could have led, or could potentially lead, to harm for patients. We do this without attributing blame or liability. We value independence, transparency, objectivity, expertise and learning for improvement in all that we do.
There are two programmes through which we deliver our patient safety investigations: national and maternity. There are differences in how they are carried out and how reports are published, but the aims are the same. That is to share learning and to make safety recommendations that improve patient safety at a national level in the NHS.
HSIB is funded by the Department of Health and Social Care and currently hosted by NHS England. We are going through organisational transition to become the Health Services Safety Investigations Body (HSSIB). At the same time our maternity investigations programme will be formed into a separate special health authority. We expect both organisations to be operational in April 2023. Source
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| Scope | Local |
|---|---|
| Language | English |
| Country | United Kingdom |
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Recent Articles
Search ArticlesReport reminds of ‘ever present’ risk of harm to patients from handover delays — HSIB
Our latest national report brings together the findings of three interim reports, published over the last 15 months, focusing on the harm caused by delays in handing over care from ambulances to emergency departments. The three reports looked at different areas; the systems in place to manage patients into, through and out of hospital, gaps in accountability for patient safety between ambulances, hospital, and social care systems and the impact of staff wellbeing impacts patient safety.
Maternity Investigation Programme Year in Review 2022/23
This is the final maternity review before HSIB transforms into the Health Services Safety Investigations Body (HSSIB) and the maternity programme becomes the Maternity and Newborn Safety Investigations (MNSI) programme, in October 2023. Highlights from the year: We have developed a family inclusivity toolkit, so we fully understand family needs during an investigation.
Annual Review 2022/23
Over the year (2022/23) we’ve published 16 investigation reports and issued 36 safety recommendations to 13 different organisations. Our HSIB maternity programme has helped identify systemic issues which contribute harm to pregnant women/people and babies. We have noted that investigation referrals relating to brain injury indicate a sustained decrease in babies with abnormal MRI results or neurological damage.
Report recommends packaging and labelling change
In this investigation, the implant is a vascular graft and is one option for haemodialysis treatment. It is designed to connect an artery to a vein and create a larger and stronger opening for blood to travel. There are different types of vascular grafts (different diameters, lengths and may be tapered or non-tapered).
Non-Executive Directors for HSSIB Board announced
The Board will be chaired by Ted Baker, who has been in his role as Chair Designate since 1 December 2022. The new Non-Executive Directors are. Mike Durkin Marisa Logan-Ward Mary Cuneen Peter Schild Marc Esmiley HSSIB will be established as an independent arms-length body in October 2023. It became a non-departmental body in the Health and Care Act 2022 that was given Royal Assent in April 2022.
Learning response review and improvement tool
The 'Learning Response Review and Improvement Tool' is intended to be used by: Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Development of this tool was informed by a research study which identified ‘traps to avoid’ in safety investigations and report writing.
Importance of non-patient facing NHS services
Non-patient facing services in HSIB investigations HSIB has carried out investigations in these areas that help stress the important role they play in keeping patients and staff safe. Decontamination of surgical instruments Our decontamination of surgical instruments investigation explored a situation where a contaminated medical device was used on a patient during a procedure.
Information for learners
Did the patient safety event happen after April 2017? We can only investigate events that occurred within NHS-funded care in England after 1 April 2017. Alternative help and support Did the event happen in NHS funded care? We can only investigate patient safety events that happened in NHS funded care in England. Alternative help and support Did the event happen in England? We can only investigate patient safety events that happened in NHS funded care in England.
Gaps in care for those with life-limiting illnesses
The report sets out an investigation we undertook examining the quality and consistency of palliative care provided to adults. Since 2004, and even with a national strategy in place since 2008, numerous publications have highlighted concerns about the limitations of the delivery of palliative and end of life care. These limitations may be more noticeable in areas where funding for services is limited or where care is being delivered across wide geographical areas.
Design of information in the workplace
Consider this situation: you are a healthcare worker called to see a patient. A patient you have never met before, in an environment you have never been to before. How do you know you are seeing the correct patient? How do you quickly and accurately access information about them? A lack of information can affect decision making, particularly in time-pressured situations.