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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.

Start date:

Report publication date:

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A nurse presses a button on a patient monitor in a critical care unit.

The use of an appropriate flush fluid with arterial lines

published
This investigation aims to understand the risks for patients associated with blood sampling from arterial line systems used in adult critical care.
Read the summary
Published

  • Theme:

    Medical devices, Medication, Checking

  • Awaiting safety recommendation responses

A male patient's hand rests on a nurse call button in a hospital bed

Positive patient identification

We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
Read the summary
Launched

  • Theme:

    Communication and decision making, Checking
A Black mother cradles her newborn baby who is asleep in her arms.

Detection of jaundice in newborn babies

We have launched an investigation into the detection of jaundice in newborn babies.
Read the summary
Launched

  • Theme:

    Neonatal, Missed diagnosis
A member of care home staff walks around a garden with their arm around the shoulders of an older person.

Local integrated investigation pilot 2: Incorrect patient details on handover

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Read the summary
Published

  • Safety recommendation responses received

The exterior front entrance of a hospital emergency department, with ambulances parked outside.

Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to emergency care

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Read the summary
Published

  • Theme:

    Emergency care
Two doctors discussing results on a clipboard.

Local integrated investigation pilot 1: Incorrect patient identification

published
Between April 2021 and April 2022 we undertook a pilot to evaluate our ability to carry out effective locality-based investigations. This investigation was undertaken as part of the pilot.
Read the summary
Published

  • Theme:

    Analysis

  • Safety recommendation responses received

A Black patient lies in a hospital bed with their eyes closed.

Invasive procedures in patients with sickle cell disease

This investigation looks at the risks for patients with sickle cell disease when they undergo invasive procedures in hospital. It explores how hospital specialities can ensure that patients with sickle cell disease are prepared for procedures which could put them at risk of a sickle cell crisis.
Read the summary
Launched

  • Theme:

    Long-term conditions, Communication and decision making
Generic image of a woman and a man, sat together, looking at work on a laptop screen

Recognition of the acutely ill infant

published
We were notified of a three-month-old infant who was admitted to hospital and discharged four hours later. The infant was re-admitted less than four hours later and sadly died of Meningococcus (serogroup B).
Read the summary
Published

  • Theme:

    Emergency care, Communication and decision making

  • Safety recommendation responses received

A sleeping newborn baby with brown hair wears an oxygen mask, with a plaster holding a tube in place on their face.

Emergency neonatal blood transfusion at birth following acute blood loss during labour and/or delivery

published
This investigation looks at the issue of emergency blood transfusions given to newborn babies who need resuscitation when they are born. Delays in neonatal blood transfusion emerged as a safety risk from investigations carried out under our maternity investigation programme.
Read the summary
Published

  • Theme:

    Neonatal, Maternity

  • Safety recommendation responses received

Image of Undiagnosed cardiomyopathy in a young person with autism

Undiagnosed cardiomyopathy in a young person with autism

published
People with additional needs receiving care in hospital may require adjustments to promote their safety and improve their experience of care. This investigation seeks to understand the safety risks associated with patients with additional needs, as highlighted in the reference event.
Read the summary
Published

  • Theme:

    Long-term conditions, Communication and decision making

  • Safety recommendation responses received

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