Telling us about a patient safety concern
- Patient safety concerns are referred to us through our website.
- Each submission is logged and stored on our database – this is to help us see emerging patterns and builds a useful picture even if we don’t end up investigating that particular case. We aim to review the submissions on a regular basis.
- We review every patient safety concern using our detailed criteria. We consider the impact, how widespread or common the safety issues are, and crucially, the potential to drive positive change and improve patient safety.
Making the decision to begin an investigation
- If we feel it meets our criteria, we’ll spend some time developing a case to investigate. This can involve research – for example reviewing literature or speaking to those outside HSIB with relevant subject expertise. We’ll then gather all the relevant documents or data.
- We hold a weekly scrutiny panel to look at developed cases. They decide on the scope of the initial investigation and also identify the right team of investigators to work on it.
How we do the preliminary investigation
- We get in touch with those involved so that everyone knows that we are going to begin our investigation. We’ll always contact the chief executive of an organisation to make sure that they are aware of the investigation.
- At this stage our team talk to those involved through a programme of interviews. Insight from relevant staff across the organisation is crucial and the focus of interviews isn’t on blame. Interviews help us to understand what happened and identify wider issues relating to patient safety.
- We then hold a debriefing session for HSIB staff on what has been discovered so far. This helps us to identify patterns and links with other events, helping us to learn as we work.
- At this point we might publish an interim bulletin if we feel that there are clear and helpful safety recommendations. Those directly involved with the investigation will receive a pre-publication version for factual comment. Interim bulletins are available to download from the relevant national investigation page.
It’s important to note that our investigations do not replace other internal NHS trust or regulatory investigations.
How we do the full investigation
- The full investigation is more detailed and builds on what we've found so far with the initial investigation.
- It involves our national investigation team and those directly involved with the case, including patients, family, carers and individual members of staff.
- Every investigation is different and we determine the best methodology to use on an individual basis. However, in most cases we will:
- Gather documents and data.
- Use interviews to gather further insight and information.
- Analyse any information we have about the incident, from a range of sources.
- Benchmark practice against national standards.
- Determine cause or contributory factors.
- Identify safety issues, safety actions that result from those, and prepare safety recommendations that improve patient safety.
As investigations can vary in length, we’ll publish key updates on the website as needed.
When the investigation is complete
- We share the safety recommendations and safety actions from the draft report with the organisations who are impacted by them.
- We’ll also ensure that staff members, patients, family members or carers directly involved with the case get a copy of the report for factual comment.
- The final copy of the report with all safety recommendations is published on this website.