Keith ConradiThis first report is the culmination of many months of rigorous and independent investigation, working closely with those involved in the incident, as well as relevant organisations and subject matter experts. Our independence allows us to make public safety recommendations to the healthcare sector, both within and outside the NHS.

The report published today is the first investigation report from the Healthcare Safety Investigation Branch. The report deliberately avoids naming the Trust where the incident occurred, and instead focusses on the system wide issues identified by the HSIB investigation, and on recommendations for improvement. 

The five safety recommendations are directed to the national bodies we consider will be most effective in bringing about the identified safety improvements. We will publish their response to our recommendations on the website. 

HSIB is a new organisation. It is the first of its kind anywhere in the world. We are evolving, and we are keen to learn from the wider healthcare system on how and where, we can add value. To that end, we welcome feedback on this first report as we strive to improve our role in enhancing patient safety.