Press releases
Our latest reports and key press coverage.
Our latest publications, with links to download the full report including safety recommendations, the associated press release and key press coverage.
For more information about our journey to become an independent non-departmental public body see the HSSIB Bill page.
For past publications see the press office archive.
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
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
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
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).
Past publications
For past publications see the press office archive.