Submit a patient safety concern

About this form

Thank you for contacting us about your patient safety concern

This form should take around 20 minutes to complete. Required fields are marked with an asterisk (*).

Please read the patient safety concern information on our website before you complete this form. It explains what a patient safety concern is, what we investigate and our position on whistleblowing.

Everything you share with us is in the strictest confidence and in line with our privacy notice.

If you would like to request this form in another format, please email referrals@hsib.org.uk. Other formats include easy read, large print, braille, or any other language or need.

Your patient safety concern

About this section

You can tell us about something that has happened or something that might happen.

Something that has happened: this could be a one-off or a series of events where something potentially dangerous has happened, whether or not someone was actually harmed.

Something that might happen: this could be a safety risk or an unsafe condition that, if not corrected, might lead to an incident which could cause harm.

We can investigate events or risks that occurred within NHS-funded care in England after 1 April 2017.

Type and frequency
Remember, we can only investigate events or risks that happened after 1 April 2017.
Select all that apply.
Organisation and location

Remember, we can only investigate patient safety concerns that relate to NHS-funded care in England.

Please tell us the organisation that your patient safety concern relates to and the location. For example the name of a hospital, GP practice, or care home.

Details of your patient safety concern

About this section

We’d like you to tell us about your patient safety concern in your own words.

There is the opportunity later in the form to attach supporting files that provide additional information.

When doing this, it’s important that you do not provide any personal identifiable information without permission. If it’s possible to identify an individual from the information you provide – directly or indirectly – this is personal identifiable information.

If you provide information that allows an individual to be identified, you must:

  • be that person
  • or, be telling us about a concern that involves a child under the age of 13 years and be their parent or legal guardian
  • or, be registered with the Office of the Public Guardian to act on the individual’s behalf (a lasting power of attorney).

We cannot use or store personal identifiable information provided without permission. Any personal identifiable information provided without permission will be deleted.

Select all that apply.
Why you think we should investigate

About this section

Although there are many factors that inform our decision to investigate a patient safety concern, we consider three main criteria:

  1. Impact: what has been the physical and psychological effect on people (including staff, patients, families and carers)? How has it affected the ability of the service to deliver safe and reliable care?
  2. Systemic risk: how common or widespread is the issue across different areas of healthcare and different locations?
  3. Learning potential: what work is already underway on the issue? Could investigation by HSIB positively influence the healthcare system, practices and safety culture?

You can find out more about our criteria for investigations on the can we look into your concern? page on our website.

Select all that apply.
About you

About this section

We’d like to find out more about you in case we need to contact you for further information.

If we think your patient safety concern could meet our investigation criteria, we may need to contact you to check details or find out more.

We record all the patient safety concerns we receive in our database. If your patient safety concern does not currently meet our investigation criteria, it may do in the future if related safety concerns are raised. At that point we may need to contact you for further information.

We’ll only keep and use your contact details for these purposes.

We respect your privacy and are committed to protecting your personal data. You can ask for your information to be updated or removed from our records at any time.

Please read the privacy notice on our website for more information.

How would you describe yourself?
Contact preference
We need to have a postal or email address, wherever possible, to acknowledge your referral and provide written information to help you. You can advise if there are communication needs we need to take into account.
Address
Telephone
Our office is open Monday to Friday, 9:00AM to 5:00PM.
24-hour format (HH:MM).e.g. to enter 'quarter past one', type 01:15 for AM or 13:15 for PM.
24-hour format (HH:MM).e.g. to enter 'quarter past one', type 01:15 for AM or 13:15 for PM.
Name
Equality and diversity

About this section

We’d like to collect this information to make sure we give everyone an equal opportunity to access our patient safety investigations. We aim to reflect the diversity of the population in our decision-making.

HSIB has a duty to pay due regard to avoid unlawful discrimination and to consider how to advance equality. The information you provide is only used for this purpose.

We respect your privacy and are committed to protecting your personal data. You can ask for your information to be updated or removed from our records at any time. Please read the privacy notice on our website for more information.

Supporting files

About this section

Please upload any files that provide additional information that supports your patient safety concern.

You can submit these file types:

  • standard office documents (Word, Excel and PowerPoint)
  • PDFs
  • images (jpg, bmp, png etc)

Only upload personal data:

  • That belongs to you, or another for who you have their consent or you’re acting as their legally appointed representative.
  • If you consent with the way in which HSIB proposes to process your information.

You can upload a total of 20.0 MB of files at a time using this form.

Please read the privacy notice on our website for more information about our data processing activities.

You can drag and drop files from your computer here or to upload.

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