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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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Mock up image of the report investigating the implantation pf wrong prostheses during joint replacement surgery

Implantation of wrong prostheses during joint replacement surgery

published
Our first complete investigation relates to the implantation of the wrong prostheses (artificial body parts) during joint replacement surgery — a surgical never event. A never event is a serious incident that is entirely preventable.
Read the summary
Published
  • Theme:

    Checking, Surgical
  • Safety recommendation responses received

Mock up image of the report investigating the management of chronic health conditions in prisons

Management of chronic health conditions in prisons

published
Each day around 120 prisoners with ongoing medication needs are moved between prisons.This investigation identifies opportunities and remedies that could be applied across the system to reduce the risk of prisoners with long term, chronic conditions being moved without crucial medication.
Read the summary
Published
  • Theme:

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

Image of patient hand in hospital bed

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

published
Research suggests that 237 million medication errors occur at some point in the medication process in England per year.When errors occur in prescribing high-risk medications for older patients with multiple medical problems, there is a significant risk of serious harm. High-risk medicines are those…
Read the summary
Published
  • Theme:

    Communication and decision making, Medication
  • Safety recommendation responses received

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Support for staff following patient safety incidents

This national learning report explores HSIB’s insights into how NHS staff are supported by their trusts following patient safety incidents, with a focus on good practice.
Read the summary
Published
  • Theme:

    NHS staff
Image of birth parent and newborn baby

Neonatal collapse alongside skin-to-skin contact

published
In March 2020 we published a national learning report to highlight the themes emerging from the initial investigations carried out as part of our maternity investigation programme.
Read the summary
Published
  • Theme:

    Communication and decision making, Maternity
Mock up image of the report investigating the summary of themes arising from the HSIB maternity programme

Summary of themes arising from the HSIB maternity programme

published
This national learning report highlights the themes emerging from the initial investigations carried out as part of our maternity investigation programme. It looks at maternity investigations carried out by HSIB between April 2018 and December 2019.
Read the summary
Published
  • Theme:

    Patient safety themes, Maternity
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