Healthcare Safety Investigation Conference cropped.jpg

Healthcare Safety Investigations Conference 2021

by Communications team

Nearly 1,200 people joined us for our second annual Patient Safety Investigation Conference on 16 September 2021, making it our biggest yet.

With people attending from all over the UK, Europe and as far away as Australia, Brazil and South Africa, the appetite to learn from our independent investigations and safety recommendations is growing.

This year’s conference focused on professional healthcare investigations, and how HSIB is training staff to conduct high quality investigations. The conference also gave people an insight into our national, COVID-19 and maternity investigations.

In the following suite of videos and slide sets we share what we have learnt from healthcare safety investigations across England and give advice and content on how you can improve safety within your own organisation.

Main session videos

Investigation science: Fundamentals of a professional safety investigation

In this session the HSIB investigation education, learning and standards team discuss the features and current progress of the science of investigation, or Investigation Science as it has been named by Dawn Benson, our head of investigation education.

The team highlights the foundations of Investigation Science in the implementation of national, organisational and team-based incident investigations in healthcare.

Professionalising the investigation workforce will make a significant contribution to healthcare improvement and learning to meet strategic, policy and regulatory requirements.

Education programme

Dr Dawn Benson guides you through the courses which are being offered by HSIB and our plans for the future. The session involves a Q&A with Dawn about the courses on offer, in particular our Level 3 Award in Healthcare Safety Investigation which is open to applicants. You can find out more by emailing:

Download the presentation

View the video

What HSIB has learned about the need for an organised approach to safety

The aim of investigating patient safety incidents is to learn from them by identifying safety recommendations for improvement. Many organisations, including HSIB, make safety recommendations. This presentation explores the types of recommendations that HSIB has made and where these recommendations have been targeted. Safety management principles are discussed, and HSIB reflects on whether these principles could help the NHS when attempting to improve safety.

Download the presentation

View the video

Breakout sessions

Below you'll find slide sets and videos from all of our breakout sessions.

Quality insights and safety improvements in maternity care

Synopsis: This workshop explored the journey of our maternity programme. It included headlines of the programmes achievements, explaining how the programme has listened, learned and improved from feedback. We shared the development of our new quality matrix and gave live examples of safety improvements made by trusts following recommendations from maternity investigations.

Download the presentation

View the video

Family engagement workshop: family and investigator perspectives on HSIB investigations

Synopsis: This workshop considered patient safety investigations from the views of a family member and an investigator. We looked at investigations in three separate areas, the initial contact, the investigation process, and the difference the investigation has made. Within these areas we discussed what has been considered helpful, and some take home messages for anyone delivering patient and family engagement within investigations.

Download the presentation

View the video

Synopsis: This session shared examples of investigations completed by HSIB during the height of the COVID-19 pandemic. This included a summary of the investigation into the supply of oxygen in hospitals and a review of 37 intrapartum stillbirths which were reported between April and June 2020. The session also considered how existing vulnerabilities within healthcare systems influenced healthcare services during the COVID-19 pandemic.

Download the presentation

View the video

Session 4: The life of a National Investigation

Synopsis: This session explored the national investigation process from referral of incidents to the publication of the report. The session will also provided detail of how we involve patients, families and service users during the investigation process.

Download the presentation

View the video (Timecode - 00:36:48)

Thank you

Thank you so much for joining our Healthcare Safety Investigations Conference 2021 on Thursday 16 September 2021.

You may also like to sign up to our email alerts where you choose what you would like to hear about, such as events or investigation reports etc.

Please fill in our form to be alerted to upcoming events and reports.

Back to news

Related news

A young Black woman works at a laptop.

Healthcare Safety Investigations Conference 2022

Read news article
Child asthma cut.jpg

Webinar: asthma management in children

Read news article
13 delegates from Ukom, with HSIB's Lesley Kay, Deinniol Owens and Keith Conradi

Knowledge exchange with Norway

Read news article
Blue capsules spill out of a foil packet.

Report shows retention of learning disability nurses is vital for consistency of medication care

Read news article
An ambulance drives at speed past the houses of parliament in Westminster.

Interim report calls for immediate action to reduce harm to patients from handover delays

Read news article