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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.

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Oxygen issues during the COVID-19 pandemic

published
We launched a national investigation into the provision of piped oxygen gas supplies to hospitals.There has been an increased demand for oxygen gas in hospital wards during the COVID-19 pandemic. COVID-19 can cause severe inflammation of the lungs affecting a patient’s ability to breathe.
Read the summary
Published
  • Theme:

    Medical devices, COVID-19
  • Awaiting safety recommendation responses

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Suitability of equipment and technology used for continuous fetal heart rate monitoring

published
We launched a national patient safety investigation into the suitability of equipment and technology used for continuous fetal heart rate monitoring during labour and birth.
Read the summary
Published
  • Theme:

    Medical devices, Maternity
  • Awaiting safety recommendation responses

Two doctors discussing results on a clipboard.

HSIB local integrated investigation pilot

published
HSIB launched a pilot programme to evaluate its ability to carry out effective locality-based investigations. Following evaluation, consideration this model may be implemented more widely by HSIB.
Read the summary
Launched
  • Theme:

    Analysis
  • Awaiting safety recommendation responses

Two doctors discussing results on a clipboard.

The assessment of venous thromboembolism risks associated with pregnancy

We have started an investigation looking at the assessment and communication of the risk of venous thromboembolism (VTE) in pregnant and postnatal women. VTE is the collective term for the formation of blood clots, including deep vein thrombosis (DVT) and pulmonary embolism (PE).
Read the summary
Launched
  • Theme:

    Maternity
CPAP machine

Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit

published
This investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.
Read the summary
Published
  • Theme:

    Respiratory, COVID-19
Image of blurred hospital

Unplanned delayed removal of ureteric stents

published
This investigation relates to patients with kidney stones who have had a ureteric stent inserted and where the stent is left in longer than planned.
Read the summary
Published
  • Theme:

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

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Surgical care of NHS patients in independent hospitals

published
We launched an investigation to support the delivery of safe care to NHS-funded patients undergoing surgery within independent (private) hospitals.
Read the summary
Published
  • Theme:

    Communication and decision making, Surgical
  • Awaiting safety recommendation responses

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Provision of care for children and young people when accessing specialist gender dysphoria services

This investigation will explore the care of patients who present to child and adolescent mental health services (CAMHS) with questions about their gender identity and are referred to specialist gender dysphoria services.
Read the summary
Launched
  • Theme:

    Access to care
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Missed detection of lung cancer on chest X-rays of patients being seen in primary care

published
We launched a national investigation into the safety risk of delayed diagnosis of lung cancer. Specifically, the investigation explored delays in patients being seen in primary care and who had a chest X-ray that had not detected cancer.
Read the summary
Published
  • Theme:

    Missed diagnosis
  • Safety recommendation responses received

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Clinical decision making: diagnosis of pulmonary embolism in emergency departments

We have started an investigation looking at the timely recognition and treatment of suspected pulmonary embolism (PE).A person suffering from a PE (a clot in the lung) requires urgent treatment to reduce the chance of significant harm or death.
Read the summary
Launched
  • Theme:

    Hospital care, Communication and decision making
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