Asking us to investigate
- Cases are referred through the safety awareness form
- Each submission is logged and stored on a database to help us identify emerging patterns and themes. This is kept under constant review
- Every submission is reviewed using our detailed criteria – we consider the impact, how widespread or common the safety issues are, and crucially, what the potential is 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 involves research and reviewing relevant literature or talking to Subject Matter Experts
- We hold a weekly scrutiny panel. They decide on the scope of any initial investigation and also identify the right team of the investigators to work on it.
How we carry out the preliminary investigation
- We’ll contact those directly involved with the case – we’ll always write to and if needed, the Chief Investigator will speak to 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. The focus isn’t on blame and insight from relevant staff across the organisation is crucial. It helps 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 (visit our latest bulletin here) if we feel that there are clear and helpful recommendations. Those directly involved with the case will receive a pre-publication version for factual comment
- All our bulletins and reports will be available here (LINK to the main Investigations page)
It’s important to note that our investigation doesn’t replace other internal Trust or regulatory investigations.
How we carry out the full investigation
- The full investigation is more detailed and builds on what we have found so far with the initial investigation
- It’ll involve the HSIB investigative team, and those directly involved with the case – this includes patients, family, carers and individual members of staff.
- Each investigation will differ, and we determine the methodology best to use for that individual investigation. 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.
Once an investigation is complete
- We share the safety recommendations and 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