Two doctors discussing results on a clipboard.

Local integrated investigation pilot 1: Incorrect patient identification


The national investigation

HSIB launched a pilot programme to evaluate its ability to carry out effective locality-based investigations. Following evaluation, this model may be implemented more widely by HSIB.

This pilot was undertaken to understand whether, using the experience gained from the maternity programme, the national investigation model can be adapted to investigate individual incidents which could Local integrated investigation pilot 2: Incorrect patient details on handover notes | HSIB develop local trust/organisation and system learning. This may further HSIB’s contribution to improvements in patient safety at local, regional and national levels.

Scope of the pilot

HSIB engaged with several acute hospitals and ambulance trusts who were asked to refer incidents that involved cross-boundary care (for example, ambulance services, acute hospitals, and primary care services).

Following referral, HSIB reviewed the incidents to consider whether to launch an investigation as part of this pilot. The HSIB investigation does not replace any trust requirements for their own local investigations.

HSIB also engaged with several internal and external stakeholders to support delivery of the pilot.

Outputs of the pilot

HSIB intends to publish up to four local investigation reports and a subsequent evaluation of the pilot. The reports will be published on this page as they are completed. The first report was published in November 2021 and subsequent reports will be published in early 2022.

Each investigation report presents findings from a single investigation. The associated safety recommendations are made specifically to the organisations involved in the investigation. Organisations are anonymised.

The reports also identify safety risks that might be addressed by future national investigation by HSIB.