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.

Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

National report published 13 October 2020.

Strokes are the fourth most common cause of death in the UK and around one in ten people die before they reach hospital. This report emphasises that if patients do survive, then the assessment of care in wards and units is key to prevent any further risk to life.

Press release: new report highlights missed opportunities in stroke aftercare (PDF)

Final report: Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke

The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

National report published 24 September 2020.

This healthcare safety investigation looks at errors when prescribing high-risk medications to older patients in hospitals with multiple medical problems.

Press release: safety body highlights deadly impact of high-risk medication errors (PDF)

Final report: The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital

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

Past publications

For past publications see the press office archive.