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 previous publications, please see the press office archive page.
Emergency response to heart attack
National report published 11 March 2021
HSIB's report says that patients suffering from a heart attack face ambulance delays that could impact their ability to have life-saving treatment.
The report highlights the case of a 61-year-old male who had a heart attack and waited just under four hours for treatment.
Residual drugs in intravenous cannulae and extension lines
National report published 3 March 2021
Our report says that powerful anaesthetic drugs left behind in intravenous tubes pose a life-threatening risk to patients.
We identified the risk after examining the case of a 42-year old male who had strong muscle relaxant accidentally flushed through his system.
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
National learning report published 25 February 2021
HSIB’s latest report identifies crucial learning from maternal death investigations undertaken during the first peak of the COVID-19 pandemic.
The report emphasises that the same key themes emerged when HSIB reviewed 19 maternal deaths that happened between March and May 2020. It also reiterates the increased risk of COVID-19 to women from Black, Asian and Minority Ethnic backgrounds.
Maternity national learning report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia
Maternity national learning report published 4 February 2021
This maternity national learning report highlights that larger than average babies are at increased risk of nerve damage, brain injury or death when their shoulders get stuck during birth.
Interim bulletin: oxygen issues during the COVID-19 pandemic
National report published 29 January
The Healthcare Safety Investigation Branch (HSIB) has been investigating piped oxygen gas supplies in hospitals and produced an early Interim Bulletin to help trusts in dealing with oxygen flow issues in their organisation.
Never events analysis report
National report published 21 January 2021
This investigation challenged the definition of 'never events' and recommended that seven Never Events on a list of 15 should be removed from the list until there are better barriers in place to reduce the risk of harm to patients.
Supporting staff after patient safety incidents
National report published 14 January 2021
This investigation identified the most important factors for successfully supporting NHS staff in the wake of safety incidents, against the backdrop of the COVID-19 pandemic.
Placement of nasogastric tubes
National report published 17 December 2020.
This investigation looked at nasogastric (NG) tubes and how previously identified safety improvements for the placement of these tubes are put into practice. Data from national reporting systems shows that there were 14 incidents of misplaced NG tubes from April to September this year.
Procurement, usability and adoption of ‘smart’ infusion pumps
National report published 3 December 2020.
We have looked at the challenges of introducing ‘smart’ infusion pumps in NHS hospitals. Although the aim of smart infusion pumps is to improve patient safety, the technology can introduce new risks.
Delays to intrapartum intervention once fetal compromise is suspected
National report published 12 November 2020.
We have identified a safety risk in maternity care relating to delays to intrapartum intervention once fetal compromise is suspected. Our review identified issues such as inadequate staffing, poor infrastructure and high workload as contributory factors to these delays.
COVID-19 transmission in hospitals: management of the risk
National report published 29 October 2020.
Helping the healthcare system reduce the spread of coronavirus (COVID-19) in hospitals is the focus of this report. It charts a four-month patient safety investigation that was launched following concern that patients were contracting COVID-19 after being admitted to hospital.
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.
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.
For previous publications see the press office archive.