HSSIB Patient Safety Investigations

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.

We have launched an investigation that explores risks to patient safety where access to, the use of, or functionality of electronic patient record (EPR) systems has been lost. That loss may be short- or long-term, and be planned or unplanned.

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades. There is concern about the decline of lithium prescribing due to it's effectiveness as a treatment for bipolar disorder.

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.

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. To date we've published two out of four reports.

These three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Currently, one of three investigation reports has been published.

We've analysed the patient safety issues frequently highlighted within prison healthcare to identify themes. Our four investigation reports in this series span emergency care response, continuity of care, data sharing and IT, and needs assessments and disability access.

This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one of the most common causes of harm from medication errors in the NHS.

This investigation explores the management of patient safety risks associated with using temporary care environments, often referred to as ‘corridor care’ and ‘temporary escalation spaces’.

We have completed a thematic review of 50 HSSIB reports to identify specific patient safety issues and learning related to electronic patient record (EPR) systems. The report includes a safety observation and local-level learning prompts around safe selection and procurement, implementation and ongoing optimisation of EPR systems.

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).

This report shares our learning about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It's intended for national and local organisations and policymakers to help inform future work to support staff in system-based investigation across the NHS in England.

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 emergency care services.

<p data-block-key="rnhp2">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 Healthcare Safety Investigation Branch (HSIB), the precursor organisation to HSSIB. Although we consider this information to be limited in its breadth and depth compared to a full HSSIB investigation, the exploratory exercise did provide evidence to support the direction any future investigations might take.</p><p data-block-key="7gabf">On 23 June 2025, the Secretary of State for Health and Social Care announced a national investigation into maternity and neonatal services. The intention is that this investigation will be rapid, system wide and report in December 2025. In light of this announcement, we paused our intention to progress investigations into maternity and neonatal services, recognising that it would be prudent to wait for the outcome of the national investigation. However, we considered that the information we collected during the exploratory review was important and could assist the national investigation. Therefore, we decided to publish this summary report.</p>

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.

The workforce challenges faced by the NHS in England present a risk to patient safety and staff wellbeing. We've undertaken five investigations to consider how working conditions can be optimised to support patient safety and NHS staff wellbeing.

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.

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.

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 the need to review existing data to better understand factors that impact on staff fatigue and steps NHS trusts can take to help manage this risk.

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.

There is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, HSSIB carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.

Independent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.

This investigation looks at the safety risk of booking systems failures. We explore the use of paper and hybrid booking systems and the production of appointment letters.

This investigation looks at the risk factors associated with the design of paediatric wards in acute hospitals for children and young people with mental health needs.

This investigation has found limited evidence that the current approach to continuous observation of adult patients at risk of self-harm on hospital wards is effective.