How a national investigation works

An older person uses a computer

Step 1 - Tell us about a patient safety concern

  • Submit your patient safety concern through this website.
  • Each submission is logged and stored on our database – this is to help us see emerging patterns and builds a useful picture even if we don’t end up investigating that particular case. We aim to review the submissions on a regular basis.
  • We review every patient safety concern using our detailed criteria. We consider the impact, how widespread or common the safety issues are, and crucially, the potential to drive positive change and improve patient safety.

Step 2 - We decide whether to start an investigation

  • If we feel your concern meets our criteria, we’ll spend some time developing a case to investigate. This can involve research – for example reviewing literature or speaking to those outside HSIB with relevant subject expertise. We’ll then gather all the relevant documents or data.
  • We hold a monthly scrutiny panel to look at developed cases. The panel decides on the scope of the initial investigation and also identifies the right team of investigators to work on it. We'll then decide whether the criteria for national investigations are met. Please note that even if they are met, we may not have capacity to initiate a preliminary investigation

Step 3 - We carry out a preliminary investigation

  • We get in touch with those involved so that everyone knows that we are going to begin our investigation. As a patient, family member or carer, we’ll make sure you know what we’re looking at and how you might be involved.
  • We also always contact the CEO of the organisation involved through a formal letter.
  • Members of the investigating team carry out a series of interviews – they’ll talk to many of those involved and work with patients and families and others to help them understand the incident better, and gain their perspective.
  • After this we hold an internal debriefing session so that all our investigators are up to speed on what we’ve found so far – this helps the wider process because even if not everyone is involved in that case, it helps our learning by showing where there could be links and connections with other areas.
  • We may publish an interim bulletin if we feel that there are clear safety recommendations or safety actions to share widely at this point. If you’ve been involved then we’ll keep you updated at key points, including sending an interim bulletin before it's published for you to comment on. Interim bulletins are also available to download from the national investigation page. 

Step 4 - We carry out a full investigation

  • It involves our whole national investigation team, staff from the organisations we investigate and a range of independent subject matter experts, who add another level of specialist knowledge to our investigations.
  • Once we go to full investigation we might need to talk to family members and patients again. We aim to be flexible and try to let you know as soon as possible.
  • Every investigation is different and we ensure that the techniques we use to carry out the investigation fit the case. However, there are broad areas that all of our investigations include:
    • Gathering of documents and data.
    • Determination of facts through a programme of interviews.
    • Analysing available information about an incident.
    • Determining of causes or contributory factors.
    • Identification of safety issues and resulting safety actions.
    • Preparation of safety recommendations to improve patient safety.

The process for a full investigation can vary so we’ll always publish key updates our website to keep everyone informed.

Step 5 - When the investigation is complete

  • Once we have completed our investigation, we’ll contact patients, family members or carers to share our findings and get your feedback and input on the draft report.
  • It’s important to ensure that everyone is involved so we’ll also share the safety recommendations, safety observations and safety actions from the draft report with the organisations impacted by them.
  • You'll receive a copy of the final report including safety recommendations. The report is then published on our website.

"The report was incredibly thorough and well written. It provided us with some missing information regarding what happened, so we now have a clearer picture." - Family feedback, 2020

Read our reports