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.

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 and report

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.

Past publications

For past publications see the press office archive.