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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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HSIB_Website_Report_Transition from child and adolescent mental health services to adult mental health services.jpg

Transition from child and adolescent mental health services to adult mental health services

published
We investigate how young people are supported in the transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS) when they turn 18 years old.
Read the summary
Published

  • Theme:

    Mental health, Access to care

  • Safety recommendation responses received

Image of ambulance in an emergency

Transfer of critically ill adults

published
This investigation – the first we launched – looks at the transfer of critically ill adults. It has previously been referred to as 'Cardiac and vascular pathways', but the original investigation was split. This is part one of the investigation.
Read the summary
Published

  • Theme:

    Hospital care, Access to care

  • Safety recommendation responses received

Image of patient getting their eyes tested

Insertion of an incorrect intraocular lens

published
Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS.Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirel…
Read the summary
Published

  • Theme:

    Checking, Surgical

  • Safety recommendation responses received

Yellow, blue and red prescription drug capsules.

Potential under-recognised risk of harm from the use of propranolol

published
This patient safety investigation explores the under recognised toxicity of propranolol in overdose.Propranolol is used to treat medical conditions including migraine, cardiovascular problems and the physical effects of anxiety.
Read the summary
Published

  • Theme:

    Communication and decision making, Medication

  • Safety recommendation responses received

A clinician preparing a site nerve block injection.

Administering a wrong site nerve block

published
This investigation seeks to identify opportunities and systemic remedies to reduce the risk of wrong site anaesthetic nerve blocks occurring. Anaesthetic nerve blocks are injections to block pain in a specific region of the body.
Read the summary
Published

  • Theme:

    Checking, Surgical

  • Safety recommendation responses received

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

An unseen patient rests their hand on a hospital bed, with an unused cannula inserted on the top of their hand.

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

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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