What we investigate

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Investigation criteria

We can investigate patient safety concerns that:

  • occur in England during the provision of healthcare services, and
  • have or may have implications for the safety of patients.

Health Services Safety Investigations Body (HSSIB) investigations can consider healthcare provided in the NHS and the independent sector.

Where an investigation relates to an incident that did not occur in the NHS, we must also consider whether NHS systems and practices could also be improved because of our investigation.

We can also be directed to investigate a patient safety concern by the Secretary of State for Health and Social Care.

Investigation criteria

The criteria is designed to allow assessment across the available evidence, extent of risk and potential for improving care provision.

Table setting out criteria for HSSIB investigations
Criterion Low Medium High
1. Systemic risk - what is the breadth of the systemic risk The systemic risk impacts on one health and care environment and/or geographical area and/or one professional group The systemic risk impacts on between two and four health and care environments and/or geographical areas and/or professional groups The systemic risk impacts on five or more health and care environments and/or geographical areas and/or professional groups
2. Potential impact - what are the impacts of the systemic risk? The systemic risk leads to low or no harm to patients, minor disruptions to continuity or reliability of care, and/or the use of health and care resources, and/or there are little or no financial impacts for the health and care system (litigation and/or financial payouts). The systemic risk leads to moderate harm to patients, moderate disruptions to contiunity or reliability of care and/or has an impact on the use of health and care resources. There are moderate financial impacts for the health and care system (litigation and/or financial payouts). The systemic risk leads to serious harm (physical or other), severe disruptions to continuity or reliability of care and/or has severe consequences for the use of health and care resources and/or it has major financial impacts for the health and care system (litigation and/or financial payouts).
3. Added value/unexplored territory - is there potential to add value by carrying out an investigation? Carrying out an investigation would add little value because other stakeholders have or are carrying out investigation or improvement work in this area. Carrying out an investigation would add value because HSSIB's involvement could strengthen current or previous investigation and improvement work. Carrying out an investigation would be highly valuable: HSSIB would be working on a systemic risk that has not been previously investigated by other stakeholders and/or where there is no on-going improvement work.
4. Potential for improvement - would an investigation drive positive change and improve patient safety? Carrying out an investigation would not drive positive change and improve patient safety. Carrying out an investigation could possibly drive postive change and improve patient safety. Carrying out an investigation would definitely drive positive change and improve patient safety.
5. Equality, diversity, inclusion and deprivation - would carrying out an investigation reduce health disparities? Carrying out an investigation would not reduce disparities in the health and care system. Carrying out an investigation may possibly reduce disparities in the health and care system. Carrying out an investigation would likely help reduce disparities in the health and care system.
6. How easy will it be to carry out an investigation? It will be straightforward/easy to carry out an investigation on systemic risk. There will be some barriers to carrying out an investigation but these can be mitigated. It will be difficult to carry out an investigation on the systemic risk.

Key principles for investigation

  1. HSSIB do not attribute blame or liability in our investigations.
  2. HSSIB underpin investigations with the most appropriate and robust safety science methodologies.
  3. HSSIB investigations take a system perspective and aim to reduce the likelihood of incidents happening.
  4. HSSIB involve patients, families, and healthcare staff in our investigations.
  5. HSSIB consider how to improve care for those subjected to health inequalities in all our investigations.
  6. HSSIB will have a multidisciplinary team approach to investigations using skilled investigators.
  7. HSSIB involve appropriate subject matter advisors in our investigations.
  8. HSSIB recommendations will be impactful, and will work with the system to ensure there is maximum effect.
  9. HSSIB will be open and transparent about how they work whilst protecting the disclosure of specific evidence that they gather during the investigations.
  10. HSSIB will undertake investigations in a timely manner, and in the most cost-effective way.