Archive

Our past publications.

Our past publications and other press coverage related to HSIB:

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

National learning report published 17 September 2020.

This national learning report highlights the themes emerging from our contact with families during our patient safety investigations.

Press release: new report emphasises importance of the ‘family voice’ in healthcare investigations (PDF)

National learning report: Giving families a voice

Neonatal collapse alongside skin-to-skin contact

National learning report published 13 August 2020.

This national learning report has a focus on the importance of clinical monitoring to ensure that babies are as safe as possible during skin-to-skin contact following birth.

Press release: new HSIB report confirms importance of clinical vigilance in the immediate postnatal period for safe care of babies (PDF)

National learning report: Neonatal collapse alongside skin-to-skin contact

Early warning scores to detect deterioration in COVID-19 inpatients

National intelligence report published 30 July 2020.

The Royal College of Physicians is responsible for the development of early warning scores for clinical deterioration and this report documents how concerns raised by HSIB were responded to.

Press release: Behind the scenes - HSIB’s rapid approach to highlighting emerging COVID-19 patient safety risks (PDF)

National intelligence report: Early warning scores to detect deterioration in COVID-19 inpatients

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

National learning report published 16 July 2020.

Delay or failure to give preventative antibiotics to mothers can leave newborn babies at risk of death or severe injury from group B strep infection.

Press release: national report highlights life threatening risk posed by delay in group B strep treatment (PDF)

National learning report: group B streptococcus

The diagnosis of ectopic pregnancy

National investigation report published 5 March 2020.

Differing levels of provision and a mismatch between capacity and demand in early pregnancy units heightens the risk that the diagnosis of this time-critical condition is delayed or missed.

Press release: safety body highlights ‘devastating impact’ of missed ectopic pregnancy (PDF)

Final report: the diagnosis of ectopic pregnancy

Press coverage

Late diagnosis of ectopic pregnancy 'putting women at risk' The Guardian, 5 March 2020.

Women are at serious risk of harm from late diagnosis of ectopic pregnancy The BMJ, 5 March 2020 (this article is behind a paywall).

Safety body highlights `devastating impact' of missed ectopic pregnancy Nursing Times, 4 March 2020.

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

National investigation report published 6 February 2020.

There has been a steady rise in the number of propranolol prescriptions issued to NHS patients. In 2017, 52 deaths were recorded as linked to propranolol overdose.

Press release and report

Press release: report highlights ‘toxic’ risk of beta blocker to prevent overdose deaths (PDF)

Final report: potential under-recognised risk of harm from the use of propranolol

Press coverage

Doctors and paramedics must be better prepared to deal with propranolol overdoses The BMJ, 11 February 2020 (this article is behind a paywall).

GPs need to be alerted to beta blocker overdose risk, says NHS safety watchdog Pulse, 6 February 2020.

‘Toxic’ risk of commonly prescribed beta blocker needs recognition Pharma Field, 6 February 2020.

Delayed recognition of acute aortic dissection

National investigation report published 23 January 2020.

Up to half of all patients who suffer an acute aortic dissection may die before reaching crucial specialist care. Our investigation identifies a number of risks in the diagnostic process which might result in the condition being missed.

Press release and report

Press release: safety body calls for earlier recognition of aortic dissection to prevent deaths (PDF)

Final report: delayed recognition of acute aortic dissection

Press coverage

Safety body calls for earlier A&E recognition of aortic dissection Nursing Times, 29 January 2020.

Acute aortic dissection is a ‘ticking time bomb’ Pharma Field, 23 January 2020.

Half of patients with acute aortic dissection in England die before reaching a specialist centre British Medical Journal, 23 January 2020 (this article is behind a paywall).

Lack of timely monitoring of patients with glaucoma

National investigation report published 9 January 2020.

Lack of timely follow-up for glaucoma patients is a recognised national issue across the NHS. Research suggests that around 22 patients a month suffer severe or permanent sight loss as a result of the delays.

Press release and report

Press release: latest HSIB report highlights ‘devastating’ impact of delays and pressure on national glaucoma services (PDF)

Final report: lack of timely monitoring of patients with glaucoma

Press coverage

Delaying an eye test for glaucoma might lead to irreparable damage The Times, 13 January 2020 (this article is behind a paywall).

NHS delays responsible for glaucoma patients going blind, says watchdog Independent, 9 January 2020.

Glaucoma patients going blind due to treatment delays, watchdog finds The Guardian, 9 January 2020.

NHS patients are being left to go BLIND because of year-long delays in getting appointments for glaucoma and other vision-robbing conditions, damning report warns Mail Online, 9 January 2020.

Detection of retained vaginal swabs and tampons following childbirth

National investigation report published 18 December 2019.

Women can be left in severe pain and at risk of infection if swabs and tampons used after childbirth are accidentally left in the vagina. This report sets out the case of Christine, a 30-year-old woman who had a surgical tampon inserted after the birth of her first child. It was left in and not discovered until five days after leaving hospital.

Press release and report

Press release: report highlights common ‘never event’ that leaves women at risk of harm after childbirth (PDF)

Final report: detection of retained vaginal swabs and tampons following childbirth

Press coverage

Report highlights common `never event' that leaves women at risk of harm after childbirth Clinical Services Journal , 13 January 2020.

Electronic prescribing and medicines administration systems and safe discharge

National investigation report published 24 October 2019.

We’ve identified a significant safety risk posed by poorly implemented electronic prescribing and medicines administration (ePMA) systems. The report comes after we looked at the case of 75-year old Ann Midson, who was left taking two powerful blood thinning medications after a mix-up at her local hospital where she was receiving treatment whilst suffering from incurable cancer.

Press release and report

Press release: safety body warns partial set up of electronic medication systems in NHS puts patients at risk (PDF)

Final report: ePMA systems and safe discharge

Press coverage

Podcast: how a communication error and subsequent medication mix up led to the death of a patient Pharmacy In Practice, 16 December 2019.

‘Significant safety risk’ surrounds e-prescribing after drug mix-up Digital Health, 6 November 2019.

NHS use of e-prescribing can be a ‘risk to patient safety’ HSJ, 28 October 2019 (this article is behind a paywall).

Electronic medication systems risk patient safety if not implemented properly, safety body warns The Pharmaceutical Journal, 24 October 2019.

Healthcare Safety Investigation Branch warns partial set up of electronic medication systems in NHS puts patients at risk National Health Executive, 24 October 2019.

Poorly implemented electronic medication systems in the NHS are putting patients at risk Pharma Field, 24 October 2019.

Report warns of electronic medication system risks Pharmacy Business, 24 October 2019.

Management of chronic health conditions in prisons

National investigation report published 10 October 2019.

Prisoners are at risk of being transferred without crucial medication, according to our national healthcare safety investigation report. Our investigation looks into the case study of Martin, a 43-year old inmate, who suffered multiple seizures after his epilepsy medication wasn’t transferred with him to a new prison.

Press release and report

Press release: gap in care for chronically ill prisoners (PDF)

Final report: management of chronic health conditions in prisons

Press coverage

Chronically ill prisoners risk of being transferred without medication because of gaps in care The BMJ, 14 October 2019 (this article is behind a paywall).

Wrong patient details on blood sample

National investigation report published 26 September 2019.

The report highlights a case where patient details became mixed up on blood samples sent from a maternity unit. In the case of mislabelling on blood transfusion samples, the impact could be devastating; there’s the potential for serious injuries and even death. But, even the delay in care resulting from wrong blood test results could cause significant psychological distress to patients.

Press release and report

Press release: safety body highlights impact of blood sampling errors across NHS

Final report: wrong patient details on blood sample

Press coverage

Blood test mix-ups hit record high The Times, 13 October 2019 (this article is behind a paywall).

Management of acute onset testicular pain

National investigation report published 12 September 2019.

Testicular torsion is a condition where the testicle twists, cuts off the blood supply and results in significant pain. It mainly affects young boys and teenagers. If not treated in time it can result in the loss of a testicle. This report sets out a number of safety recommendations to improve diagnosis and treatment of testicular torsion.

Press release and report

Press release: safety body calls for speedier diagnosis of time-critical testicular torsion (PDF)

Final report: management of acute onset testicular pain

Press coverage

Student left in severe pain for six days and had testicle removed after multiple NHS errors iNews, 13 September 2019.

Student had to have testicle removed after 5 different GPs missed signs of 'medical emergency' The Telegraph, 12 September 2019.

University student had testicle removed due to NHS error, investigation finds Evening Standard, 12 September 2019.

Student had to have testicle removed after errors in medical care The Guardian, 12 September 2019.

Student had to have testicle removed after health blunders Metro, 12 September 2019.

'NHS errors' leave university student, 20, with one testicle Manchester Evening News, 12 September 2019.

University student, 20, lost his right testicle 'because it took doctors SIX DAYS to notice it had twisted around and cut off blood supply' Daily Mail, 12 September 2019.

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

National investigation report published 18 July 2019.

X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk. The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients.

Press release and report

Press release: HSIB latest report focuses on technology to reduce risk of x-ray findings getting lost (PDF)

Final report: failures in communication or follow-up of unexpected significant radiological findings

Press coverage

Technology could provide safety net for scan and x ray results lost in the system The BMJ, 19 July 2019 (this article is behind a paywall).

Undetected button and coin cell battery ingestion in children

National investigation report published 27 June 2019.

We've put forward safety recommendations around product safety, public awareness and clinical decision making, to prevent serious injuries or death from the unknown ingestion of button and coin cell batteries. It follows a reference event where a child died following the unknown and undetected ingestion of a coin cell battery.