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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:

Clear All
A member of hospital staff from the sterile services department cleans surgical instruments, wearing scrubs, hair net, gloves and a mask.

Decontamination of surgical instruments

published
Detailed examination of how the risk of contamination is currently managed within NHS trusts. Our investigation identifies regulatory and assurance gaps, plus four safety recommendations to address them.
Read the summary
Published
  • Theme:

    Hospital care, Surgical
  • 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

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

Two young people wearing rainbow bracelets hold hands outside in the sunshine.

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

published
This investigation explores 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
Published
  • Theme:

    Access to care
  • Awaiting safety recommendation responses

A mother holds the feet of premature twin babies.

Management of preterm labour and birth

Preterm birth is one of the main causes for under-five mortality (death) and disability worldwide. 60% of twin pregnancies result in premature birth. This investigation considers the existing knowledge and management of preterm labour and birth of twins.
Read the summary
Launched
  • Theme:

    Maternity
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Clinical decision making: diagnosis of pulmonary embolism in emergency departments

published
A person suffering from a pulmonary embolism (PE) requires urgent treatment to reduce the chance of significant harm or death. Any delay in recognising the symptoms of PE and treatment of the suspicion of PE increases risk that a patient may suffer harm.
Read the summary
Published
  • Theme:

    Hospital care, Communication and decision making
  • Awaiting safety recommendation responses

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Never events: analysis of HSIB's national investigations

published
This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.
Read the summary
Published
  • Theme:

    Never events
  • Safety recommendation responses received