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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.

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Image of button batteries

Undetected button/coin cell battery ingestion in children

published
This investigation looks at the undetected ingestion of button/coin cell batteries in children. It follows a reference event where a child died following the unknown and undetected ingestion of a coin cell battery.
Read the summary
Published
  • Theme:

    Emergency care, Communication and decision making
  • Safety recommendation responses received

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Recognising and responding to critically unwell patients

published
Problems in recognising and responding to deteriorating patients continues to be a major source of severe harm and preventable death in hospitals. Previous research has shown that up to a quarter of preventable deaths are related to failures in clinical monitoring.
Read the summary
Published
  • Theme:

    Hospital care, Communication and decision making
  • Safety recommendation responses received

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Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia

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
  • Safety recommendation responses received

Mock up image of the report investigating the assessment of venous thromboembolism risks associated with pregnacy

Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

published
Every year in the UK over 100,000 people have a stroke. Patients who are admitted to hospital for any reason, including stroke, are assessed for their risk of developing blood clots in their veins which may arise due to being less active than usual.
Read the summary
Published
  • Theme:

    Acute
  • Safety recommendation responses received

Image of blurred hospital

COVID-19 transmission in hospitals: management of the risk - a prospective safety investigation

published
This prospective patient safety investigation looks at how hospitals can minimise the likelihood of patients catching coronavirus (COVID-19) on acute hospital wards.
Read the summary
Published
  • Theme:

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

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Giving families a voice: HSIB’s approach to patient and family engagement during investigations

published
This national learning report highlights the themes emerging from our contact with families during our patient safety investigations.Our national learning reports describe common themes and findings that come out of our national investigation programme and our maternity investigation programme.
Read the summary
Published
  • Theme:

    Patient and family
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Early warning scores to detect deterioration in COVID-19 inpatients

published
This national intelligence report provides insight into a safety risk when using early warning scores to detect deterioration in patients with coronavirus (COVID-19) on general hospital wards.
Read the summary
Published
  • Theme:

    Hospital care, Coronavirus (COVID-19)
Image of ultrasound

The diagnosis of ectopic pregnancy

published
An estimated 12,000 women experience an ectopic pregnancy each year in the UK. Ectopic pregnancy occurs when the fertilised egg implants outside the uterus, usually in the Fallopian tube. If it’s left untreated, it can rupture and cause internal bleeding.
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Published
  • Theme:

    Emergency care, Communication and decision making
  • Safety recommendation responses received

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Response of NHS 111 to the COVID-19 pandemic

We have launched a national investigation into NHS 111’s response to callers reporting potential symptoms of COVID-19 during the pandemic.NHS 111 is the 24/7 telephone and online service for people seeking advice and information about urgent medical problems. The NHS 111 telephone service adapted t…
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Launched
  • Theme:

    Emergency care, Coronavirus (COVID-19)
Image of patient hand in hospital bed

Residual drugs in intravenous cannulae and extension lines

published
Our investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines.
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Published
  • Theme:

    Medical devices, Checking
  • Safety recommendation responses received