Each year we investigate up to 30 incidents where there are significant concerns around healthcare safety in England. Our investigations cover incidents that have happened since 1 April 2017.
We share what we learn across the whole of the healthcare system for the benefit of everyone who is cared for by it and works in it.
We are not a complaints investigation service and we don’t investigate every incident that is shared with us. However, every submission of the safety awareness form is reviewed and logged in our database. This helps us to build insight and see patterns of safety issues over time.
How we decide to start an investigation
When you let us know about an incident through the safety awareness form, we review what you’ve told us carefully using a set of detailed criteria. This helps us to decide whether an investigation is likely to help us to learn something new, which can be shared with the whole healthcare system to make things better for everyone working in it and being cared for by it.
These are the things we consider when we’re making this decision.
1 Outcome impact
First, we consider the impact that a safety issue has had - or is having - on people and services across the healthcare system. This is because we need to focus our attention on the safety issues that have the most serious and severe impacts.
We will consider the impact on people, such as physical and emotional harm suffered by patients, families, caregivers and staff. We consider the impact on health services, such as whether there is reduced ability to deliver safe and reliable care to patients. And we consider the broader impact on the public, such as whether there has been a broader loss of confidence in the safety of care being delivered.
2 Systemic risk
Second, we consider how widespread and how common a safety issue is across the healthcare system. This is because one of our aims is to focus on safety issues that span different parts of the healthcare system and that can cause problems in many different locations.
We consider the range of care settings and organisations that might be affected by a safety issue, or that might need to change the way they work to address a safety issue. We consider whether a safety issue has not previously attracted the level of attention it deserves. And we consider how long a safety issue has existed, how persistent it is and how likely it is to get worse or spread further in future.
3 Learning potential
Third, we consider the potential for an HSIB investigation to lead to positive changes and improvements to patient safety across the healthcare system. We consider how likely it is that an investigation will produce important new knowledge or new information about a patient safety issue.
We consider whether an investigation is likely to lead to considerable improvements to the safety of healthcare services, such as changes to how services are organised and delivered. We consider what actions are already being taken by other organisations, and if HSIB might be able to add a different perspective. And we consider how practical it will be to conduct a rigorous, effective national safety investigation and develop influential recommendations that will improve safety.
Why we do this
Our purpose is to improve patient safety through effective and independent investigations that do not apportion blame or liability. Asking ourselves these questions helps us to focus our efforts on investigations that will have the biggest potential benefit to the healthcare system as a whole and to the people who are cared for by it and work in it.
Our investigation process allows us to learn over time and through repeating our analysis. We use a range of methodologies, depending on the type of investigation.
We work with everyone who was involved in the incident or who were witnesses.
We may issue interim safety recommendations as we go through an investigation, and also publish what actions have already been taken.
The final report will identify the facts, as assessed through the investigation. It will set out what safety actions have already been taken and make recommendations for organisations across the healthcare sector.
If we can't help
Find out more about more about the other organisations who are here to support you with a specific complaint about a health safety incident.Find out more about organisations who can support you