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Although funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement, we operate independently. We're also independent from regulatory bodies like the Care Quality Commission (CQC). By offering a new perspective and developing meaningful and influential recommendations we aim to drive positive change at a wider level.

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Failures in communication or follow-up of unexpected significant radiological findings

Read our latest investigation report, including safety recommendations and observations.

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Featured news
18 Jul

Latest HSIB report focuses on technology to reduce risk of X-ray findings getting lost

  • Written by: Communications team

The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this investigation. In that event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.


Any person, group or organisation can share cases for potential investigation via the safety awareness form. Each submission is reviewed against our criteria, and an important part of assessment is whether we can learn something new that improves practice across the health system. We use a range of approaches focusing on establishing cause and identifying risk.

Our current investigations

Tell us about a patient safety concern

Link to the page with our safety awareness form