Reports and publications

We routinely publish an annual review, interim bulletins, investigation reports and responses to our national investigations and national learning reports.

                HSIB Annual Review 2021-22.

Annual Review

Our fifth annual review demonstrates the work we have done during 2021/22.

Our investigations for both the maternity and national programmes continued at pace throughout the year, despite the pressures created by the coronavirus (COVID-19) pandemic.

We have worked hard to provide useful safety recommendations to the healthcare system and to NHS trusts in order to help improve patient safety.

Highlights include:

  • the development of our investigation education team
  • trialling a model of investigating localised patient safety incidents in the NHS
  • the formal establishment of our Citizens’ Partnership

Read the Annual Review 2021/22 (PDF)

                Maternity year in review 2021/22

Maternity investigation programme year in review

Our latest maternity investigation programme year in review demonstrates the work we have carried out during 2021/22.

The maternity investigation programme has continued to develop its approach to investigations and how we work with families and NHS trusts. This has remained particularly important during the coronavirus (COVID-19) pandemic.

Highlights over the last year include:

  • 706 reports completed
  • a 9-percentage point reduction in the number of babies with an abnormal MRI or evidence of neurological damage, from babies referred in 2020/21 compared to 2019/20 (where consent to access medical records was given)
  • more than 1,740 safety recommendations to NHS trusts addressing a wide range of issues
  • introduction of a newsletter to support NHS trusts to share the improvements they have made in response to safety recommendations - this is providing learning opportunities across England and beyond.

Read the maternity investigation programme year in review 2021/22 (PDF)


National investigation programme

As part of our national investigations programme we publish interim bulletins and a final report with safety recommendations for each investigation. These documents are available to download as PDFs from individual investigation pages. We also publish responses from national bodies to our safety recommendations on individual investigation pages. You can find all of our national investigations in the investigation section.

Maternity investigations programme

The way we work and report on maternity investigations is different to our national investigations. Individual maternity investigation reports are shared with the family, the NHS trust and the healthcare professionals who were involved in the incident. Unlike our national investigation reports, we don’t publish individual maternity investigation reports.

As part of our maternity investigations programme we publish thematic reports and an annual review. Find out more on the maternity reports and publications page

National learning reports

We publish national learning reports that describe common themes and findings that arise from both our national investigations programme and maternity investigations programme. We use the information from these national learning reports to inform future HSIB investigations. You can find all of our national learning reports in the investigations section.


Equality in our workforce

This report reviews data on staff we recruited in that year by protected characteristic, against data from the previous year, to understand any improvements or areas where we need to focus more to increase diversity in the workforce. The report sets out actions that have been undertaken and future actions to help us achieve this aim. It also shares the data for the make up of the workforce by protected characteristics.

Staff survey results

In 2019 HSIB launched its first full staff survey. We had a response rate of over 91% and some extremely positive outcomes with a significant number of staff feeling proud of our organisation and wanting to be part of our organisation.

We have published the results of our survey as we have a desire to be open, honest and transparent in everything we do.

We know we still have work to do in some areas and we are working with staff to ensure our action plan is a success.

Download and view the questions and response rates from the HSIB staff survey

Documents in other formats

For documents in another format or language, including British Sign Language, please email: