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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_Oxygen issues during the Covid-19 pandemic.jpg

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

A microscopic view of the coronavirus. They appear as blue spheres with spikes sticking out of them.

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…
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Published
  • Theme:

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

Image of nurse wearing PPE

Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response

published
This national intelligence report provides insight into a safety risk related to PPE requirements for care workers delivering homecare during the COVID-19 response.
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Published
  • Theme:

    Coronavirus (COVID-19)
CPAP machine

Treating COVID-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit

published
This investigation looked into the safety risk of treating patients with coronavirus (COVID-19) with Continuous Positive Airway Pressure Ventilation (CPAP) outside of critical care units.
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Published
  • Theme:

    Respiratory, Coronavirus (COVID-19)
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.
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Published
  • Theme:

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

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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.
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Published
  • Theme:

    Hospital care, Coronavirus (COVID-19)
Image of call centre support

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 exhausted doctor in PPE

Maternal death: learning from maternal death investigations during the first wave of the COVID-19 pandemic

published
We have carried out a themed review of our maternal death investigations during the coronavirus (COVID-19) pandemic.
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Published
  • Theme:

    Coronavirus (COVID-19), Maternity
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