The Healthcare Safety Investigation Branch (HSIB) conducts independent investigations of patient safety concerns in NHS-funded care across England.
Most harm in healthcare results from problems within the systems and processes that determine how care is delivered. Our investigations identify the contributory factors that have led to harm or have the potential to cause harm to patients. The recommendations we make aim to improve healthcare systems and processes in order to reduce risk and improve safety.
Our organisation values independence, transparency, objectivity, expertise and learning for improvement.
We work closely with patients, families and healthcare staff affected by patient safety incidents, and we never attribute blame or liability to individuals.
Our team of investigators and analysts have diverse experience working in healthcare and other safety critical industries and are trained in human factors and safety science. We consult widely in England and internationally to ensure that our work is informed by appropriate clinical and other relevant expertise.
We undertake patient safety investigations through two programmes.
Our national investigations can encompass any patient safety concern that occurred within NHS-funded care in England after 1 April 2017. We consider the requirement to investigate potential incidents or issues based on wide sources of information including that provided by healthcare organisations and our own research and analysis of NHS patient safety systems.
We decide what to investigate based on the scale of risk and harm, the impact on individuals involved and on public confidence in the healthcare system, as well as the potential for learning to prevent future harm. We welcome information about patient safety concerns from the public, but we do not replace local investigations and cannot investigate on behalf of families, staff, organisations or regulators.
Our investigation reports identify opportunities for relevant organisations with power to make appropriate improvements though:
- ‘Safety recommendations’ made with the specific intention of preventing future, similar events.
- ‘Safety observations’ with suggested actions for wider learning and improvement.
Our reports also identify actions required during an investigation to immediately improve patient safety. Organisations subject to our safety recommendations must send their response to us within three months. These responses are published on our investigation pages.
Find out more in the investigations section.
From 1 April 2018, we became responsible for all patient safety investigations of maternity incidents occurring in the NHS which meet criteria for the Each Baby Counts programme.
The purpose of this programme is to achieve rapid learning and improvement in maternity services, and to identify common themes that offer opportunity for system-wide change. For these incidents HSIB’s investigation replaces the local investigation, although the trust remains responsible for Duty of Candour and for referring the incident to us.
We work closely with parents and families, healthcare staff and organisations during an investigation. Our reports are provided directly to the families involved and to the trust. The trust is responsible for actioning any safety recommendations we make as a result of these investigations.
We have been operating in all trusts since 1 April 2019. Our longer-term aim is to make safety recommendations to national organisations for system-level improvements in maternity services. These will be based on common themes arising from our trust-level investigations.
Find out more in the maternity investigations section.
We conduct independent investigations and make independent judgements. We are funded by the Department of Health & Social Care and hosted by NHS England and NHS Improvement.
In September 2017, the Government published the Health Service Safety Investigations Bill (HSSIB) in draft. The legislation will allow HSIB to become a fully independent investigations body responsible for finding answers, giving safety recommendations and embedding new practices across the NHS.
Central to this will be a commitment to a no-blame approach, encapsulated by the idea of investigations providing a ‘safe space’ in which participants, including patients, families and staff, can share information in the knowledge that it will not be disclosed except when there is a serious and continuing risk to patient or public safety, or if required by an order of the High Court.
The draft Bill underwent pre-legislative scrutiny by a Joint Committee of the House of Lords and House of Commons from May to July 2018. The Committee published its report in August 2018 and the government published a response to this report in December 2018.
We hope that when parliamentary time allows, we will be established as an independent public body. Full information about the draft Bill is available on the Department of Health and Social Care website.