National investigations

Tell us about a patient safety concern
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Complete

Provision of mental health care to patients presenting at the emergency department

  • Start date: 20 Sep 2017
  • Theme: Mental health

Complete

Piped supply of medical air and oxygen

  • Start date: 20 Nov 2018
  • Theme: Never events

Complete

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

  • Start date: 24 Oct 2018
  • Theme: Medication

Complete

The diagnosis of ectopic pregnancy

  • Start date: 18 Oct 2018
  • Theme: Delayed diagnosis

Complete

Management of chronic health conditions in prisons

  • Start date: 16 Oct 2018
  • Theme: Transfers

Complete

Electronic prescribing and medicines administration systems and safe discharge

  • Start date: 12 Oct 2018
  • Theme: Medication

Complete

Undetected button/coin cell battery ingestion in children

  • Start date: 1 Aug 2018
  • Theme: Missed diagnosis

Complete

Failures in communication or follow-up of unexpected significant radiological findings

  • Start date: 10 Sep 2018
  • Theme: Communication

Complete

Management of acute onset testicular pain

  • Start date: 27 Jun 2018
  • Theme: Primary care

Complete

Recognising and responding to critically unwell patients

  • Start date: 12 Oct 2017
  • Theme: Acute

Complete

Implantation of wrong prostheses during joint replacement surgery

  • Start date: 4 Dec 2017
  • Theme: Surgery

Complete

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

  • Start date: 18 Oct 2017
  • Theme: Mental health

Complete

Administering a wrong site nerve block

  • Start date: 12 Sep 2017
  • Theme: Never events

Complete

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

  • Start date: 7 Feb 2019
  • Theme: Acute

Complete

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

  • Start date: 18 Feb 2019
  • Theme: Medication

Complete

Insertion of an incorrect intraocular lens

  • Start date: 29 Nov 2017
  • Theme: Surgery

Complete

Design and safe use of portable oxygen systems

  • Start date: 29 Nov 2018
  • Theme: Acute

Ongoing

Recognition of the acutely ill infant

  • Start date: 20 Mar 2019
  • Theme: Missed diagnosis

Complete

Transfer of critically ill adults

  • Start date: 20 Jul 2017
  • Theme: Transfers

Complete

Lack of timely monitoring of patients with glaucoma

  • Start date: 10 May 2019
  • Theme: Outpatients

Complete

Wrong patient details on blood sample

  • Start date: 16 May 2019
  • Theme: Acute

Complete

Detection of retained vaginal swabs and tampons following childbirth

  • Start date: 11 Jul 2019
  • Theme: Acute

Complete

Inadvertent administration of an oral liquid medicine into a vein

  • Start date: 14 Nov 2017
  • Theme: Medication

Complete

Delayed recognition of acute aortic dissection

  • Start date: 20 Jul 2017
  • Theme: Delayed diagnosis

Complete

Undiagnosed cardiomyopathy in a young person with autism

  • Start date: 15 May 2019
  • Theme: Undiagnosed condition

Ongoing

Procurement, usability and adoption of ‘smart’ infusion pumps

  • Start date: 21 Aug 2019
  • Theme: Equipment and technology

Ongoing

Prescribing and administering insulin from a pen device in hospital

  • Start date: 24 Sep 2019
  • Theme: Medication

Ongoing

Medicine omissions in learning disability secure units

  • Start date: 30 Sep 2019
  • Theme: Mental health

Ongoing

Outpatient appointments intended but not booked after inpatient stays

  • Start date: 15 Oct 2019
  • Theme: Outpatients

Ongoing

Placement of nasogastric tubes

  • Start date: 9 Oct 2019
  • Theme: Never events

Ongoing

Residual drugs in cannulae and extension lines

  • Start date: 11 Dec 2019
  • Theme: Medication

Complete

Unplanned delayed removal of ureteric stents

  • Start date: 7 Oct 2019
  • Theme: Acute

Ongoing

Delays to intrapartum intervention once fetal compromise is suspected

  • Start date: 10 Dec 2019
  • Theme: Maternity

Ongoing

Timely detection and treatment of spinal nerve compression (cauda equina syndrome) in patients with back pain

  • Start date: 8 Oct 2019
  • Theme: Acute

Ongoing

Wrong site surgery – wrong patient

  • Start date: 21 Nov 2019
  • Theme: Never events

Complete

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

  • Start date: 4 Feb 2020
  • Theme: Family engagement

Complete

Summary of themes arising from the HSIB maternity programme

  • Start date: 1 Jan 2020
  • Theme: Maternity

Ongoing

Wrong site surgery – wrong tooth extraction

  • Start date: 3 Mar 2020
  • Theme: Never events

Ongoing

Emergency response to heart attack

  • Start date: 23 Jan 2020
  • Theme: Cardiac and vascular pathways

Ongoing

Management of chronic asthma in children aged 16 years and under

  • Start date: 25 Mar 2020
  • Theme: Long-term conditions

Complete

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

  • Start date: 3 Feb 2020
  • Theme: Maternity

Ongoing

Timely recognition and treatment of suspected pulmonary embolism in inpatients

  • Start date: 17 Mar 2020
  • Theme: Acute

Ongoing

Suitability of equipment and technology used for continuous fetal heart rate monitoring

  • Start date: 10 Dec 2019
  • Theme: Maternity

Complete

Early warning scores to detect deterioration in COVID-19 inpatients

  • Start date: 8 Apr 2020
  • Theme: Coronavirus (COVID-19)

Ongoing

Never events: exploration through HSIB’s national investigation programme

  • Start date: 24 Feb 2020
  • Theme: Never events

Complete

Neonatal collapse alongside skin-to-skin contact

  • Start date: 23 Jan 2020
  • Theme: Maternity

Complete

PPE: care workers delivering homecare during the COVID-19 response

  • Start date: 27 Aug 2020
  • Theme: Coronavirus (COVID-19)

Ongoing

Supporting staff after patient safety incidents

  • Start date: 3 Jun 2020
  • Theme: NHS staff

Ongoing

COVID-19 transmission in hospitals: management of the risk

  • Start date: 18 Jun 2020
  • Theme: Coronavirus (COVID-19)

Ongoing

Maternal death national learning report

  • Start date: 1 Jun 2020
  • Theme: Maternity