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National investigations

What is an HSIB National Investigation?

Our national investigations are designed to improve patient safety on a national level, and promote learning across the NHS. Unlike our maternity investigations, they do not replace local serious incident investigations within trusts.

How our national investigations work

If we feel that a serious incident presents a wider safety risk across the NHS, then we will investigate the incident in depth. This incident then triggers the investigation and we call it the ‘reference event’.

Our team will investigate the incident in a number of ways. This might include observation work – going to the site where the incident occurred to see how work is done on a day-to-day basis. Investigators may interview the NHS staff involved in the incident, and they might also collect physical evidence at the site as well.

A family talk to an investigator

Involving family

Family involvement is also key to the work we do and we involve the family’s perspective of what went wrong, how it went wrong and the circumstances that surrounded the incident. We will also ask the patient's or the family’s permission before we access medical files.

Read our Safeguarding statement

Involving experts

Once we’ve carried out the reference event investigation, it allows us to identify the key lines of enquiry needed for the national element of the investigation.

This means that we investigate key points from the reference event that are happening all over the country, in multiple NHS trust and in multiple areas.

At this stage, we might involve subject matter advisors. Depending on the incident this could be a paediatric consultant for example, or an expert in mental health. They advise on any necessary elements, whether clinical or non-clinical areas.

We also engage with national bodies that have an interest in the area we’re investigating.

Working with organisations

When we begin an investigation, we engage with organisations to ensure they understand HSIB and our work. Our chief investigator will write to, and if possible speak to, the chief executive of the NHS trust or organisation.  

One of our objectives is learning through improvement. We aim to use findings to deliver practical solutions, address causes and contributory factors and provide support to increase capability within local NHS systems.

Safety recommendations

After our team of investigators and analysts have evaluated all the evidence that we’ve gathered, we’re ready to make safety recommendations issued in a final report.

These safety recommendations are made at a national level, to the bodies best placed to drive the action forward such as the Department of Health and Social Care, the medical royal colleges or NHS England and NHS Improvement. We do not make safety recommendations to the trust where the incident took place.

Our reports are published on our website and organisations are requested to respond within 90 days. These responses are then published on our website.

"The investigators were kind and compassionate throughout the process and did a good job putting us at ease. I truly appreciated it." - Investigation feedback 2020

Somebody thumbing through reports

Read about our investigations

Spanning a wide range of clinical themes, our national investigations aim to bring about real, system-wide change across the NHS. Our investigations page hosts all interim bulletins reports and safety recommendations published since HSIB was started in 2017.

More on investigations


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Being an investigator

We often get asked how our investigations differ from those carried out by trusts, or what an investigator does. A few of our investigators explain.

Find out more