Maternity investigations 2.jpg

Investigations and reports

As part of our national investigations programme, we publish bulletins and a final report with safety recommendations for each investigation. These documents are available to download as PDFs from individual investigation pages and in accessible format. We also publish responses from national bodies to our safety recommendations on individual investigation pages.

Start date:

Report publication date:

Clear All
Coronavirus

Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020

published
The number of intrapartum stillbirths referred to the Healthcare Safety Investigation Branch (HSIB) between April and the end of June 2020 increased compared to the same time in the previous year.The data initiated an HSIB national learning report which explored the findings from our maternity inve…
Read the summary
Published
  • Theme:

    COVID-19, Maternity
  • Awaiting safety recommendation responses

Image of child with asthma inhaler

Management of chronic asthma in children aged 16 years and under

published
Asthma is the most common lung disease in the UK. 1.1 million children are diagnosed with the condition.Our investigation looked at the risks involved in the management of children aged 16 years and under diagnosed with asthma.
Read the summary
Published
  • Theme:

    Long-term conditions, Access to care
  • Safety recommendation responses received

Generic image of a woman and a man, sat together, looking at work on a laptop screen

A thematic analysis of HSIB's first 22 national investigations

published
HSIB has analysed its first 22 HSIB national investigations to identify the recurring patient safety themes and to explore the impact so far of the 85 recommendations we have made to address them. The work was undertaken after it was recognised that similar issues were arising in our investigations…
Read the summary
Published
  • Theme:

    Analysis
Image of patient receiving an eye examination

Lack of timely monitoring of patients with glaucoma

published
Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.
Read the summary
Published
  • Theme:

    Access to care, Follow-up care
  • Safety recommendation responses received

Mock up image of the report investigating the outpatient appointments intended but not booked after inpatients stays

Outpatient appointments intended but not booked after inpatient stays

published
We identified a safety risk involving outpatient follow-up appointments which are intended but not booked after an inpatient stay.If a patient does not receive their intended follow-up appointment, it could lead to patient harm owing to delayed or absent clinical care and treatment.
Read the summary
Published
  • Theme:

    Access to care, Follow-up care
  • Awaiting safety recommendation responses

Surgical instruments.jpg

Decontamination of surgical instruments

This investigation seeks to explore what systems are in place to manage the decontamination process and prevent incorrectly decontaminated surgical instruments from being used on patients.
Read the summary
Launched
  • Theme:

    Hospital care, Surgical
HSIB_Website_Report_Timely detection and treatment of spinal nerve compression.jpg

Timely detection and treatment of cauda equina syndrome

published
We have identified a patient safety risk involving the timely detection and treatment of non-malignant spinal cord compression (cauda equina syndrome).
Read the summary
Published
  • Theme:

    Emergency care, Access to care
  • Awaiting safety recommendation responses

HSIB_Website_Report_Emergency response to heart attack.jpg

Emergency response to heart attack

published
Our investigation looked at the emergency response to heart attack across the NHS in England.
Read the summary
Published
  • Theme:

    Emergency care, Access to care
  • Safety recommendation responses received

HSIB_Website_Report_Procurement, usability and adoption of ‘smart’ infusion pumps.jpg

Procurement, usability and adoption of ‘smart’ infusion pumps

published
Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks. This investigation focused on understanding the challenges involved in introducing smart infusion pump technology within NHS hospitals.
Read the summary
Published
  • Theme:

    Medical devices, Communication and decision making
  • Safety recommendation responses received

Mock up image of the report investigating the wrong site surgery - wrong tooth extraction

Wrong site surgery – wrong tooth extraction

published
Our investigation looked at the risks to identifying the correct tooth for extraction in dental practice.
Read the summary
Published
  • Theme:

    Checking, Surgical
  • Safety recommendation responses received

Page 1 of 7