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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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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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Wrong site surgery – wrong patient: invasive procedures in outpatient settings

published
We started an investigation looking at the risks involved in the correct identification of patients in outpatient departments. Correct identification is crucial to make sure they receive the right clinical procedure.
Read the summary
Published
  • Theme:

    Checking, Surgical
  • Safety recommendation responses received

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

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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.
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Published
  • Theme:

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

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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…
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Published
  • Theme:

    Analysis
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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.
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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

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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