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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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The use of an appropriate flush fluid with arterial line

This investigation looks at the risks to critically ill patients when the wrong fluid is attached to an arterial line.
Read the summary
Launched
  • Theme:

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

published
This national investigation looks into the safety risk of delayed diagnosis of lung cancer. Specifically, the investigation explores 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

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 notes

published
This investigation is the second part of a pilot programme which aims to evaluate HSIB's ability to carry out effective locality-based investigations. Following evaluation, we'll consider this model for implementation more widely by HSIB.
Read the summary
Published
  • Awaiting safety recommendation responses

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

Identification of critical patient information at the bedside – Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

This investigation explores the challenges NHS hospital staff face when trying to access key information about their patients, at the patient bedside.
Read the summary
Launched
  • Theme:

    Cardiac, Communication and decision making
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Surgical care of NHS patients in independent hospitals

published
This investigation looks at 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
  • Safety recommendation responses received

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
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Administering high strength insulin from a pen device in hospital

We’ve launched a national investigation looking at administering insulin from a pen device in hospitals.One in six hospital beds in England are occupied by someone who has diabetes. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.
Read the summary
Launched
  • Theme:

    Medication, Checking
Older male man lies on a bed with his worried wife sitting with him, holding his hand.

Unintentional overdose of morphine sulfate oral solution

published
In this investigation we share Len's story. He took an accidental overdose of morphine sulfate oral liquid while at home. We've made two safety observations, relevant to manufacturers of morphine liquids, and to encourage participation in HSIB investigations.
Read the summary
Published
  • Theme:

    Medication
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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
  • Safety recommendation responses received

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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, Coronavirus (COVID-19)
  • Safety recommendation responses received

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