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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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A male patient's hand rests on a nurse call button in a hospital bed

Positive patient identification

We've undertaken several investigations where misidentification of patients has been an important part of a patient safety event. This national learning report collates findings and identifies how these misidentifications have been able to happen.
Read the summary
Launched
  • Theme:

    Communication and decision making, Checking
A doctor comforts a woman lying in a hospital bed.

Perimortem caesarean section during the management of cardiac arrest in pregnancy

This national learning report brings together safety recommendations and learning from 21 cases of maternal death where perimortem caesarean section was undertaken.
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Launched
  • Theme:

    Cardiac, Maternity
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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

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…
Read the summary
Published
  • Theme:

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

A doctor comforts a woman lying in a hospital bed.

Risk assessments during the maternity pathway

This national learning report looks at the application of risk assessments in maternity care and how risk assessments inform and impact on aspects of the perinatal pathway.
Read the summary
Launched
  • Theme:

    Maternity
Image of birth parent with a newborn baby

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

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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.
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Published
  • Theme:

    Patient and family
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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Severe brain injury, early neonatal death and intrapartum stillbirth associated with group B streptococcus infection

published
In February 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.These initial investigations were carried out between April 2018 and December 2019. One of the themes highlighted wa…
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Published
  • Theme:

    Communication and decision making, Maternity
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
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