The programmes of investigation
These complex and wide-ranging investigations focus on safety risks that are common throughout the NHS. We identify the need to investigate potential incidents or issues based on many sources of information including that provided by healthcare organisations, the public and our own research and analysis of NHS patient safety systems. You can tell us about a safety risk or incident that concerns you by emailing firstname.lastname@example.org.
We decide what to investigate based on the scale of risk and harm, the impact on individuals involved and on public confidence in the healthcare system, as well as the potential for learning to prevent future harm. We welcome information about patient safety concerns from the public, but we cannot investigate on behalf of families, staff, organisations or regulators.
Our approach is to identify a ‘reference event’, this is a patient safety incident that has been referred to us or that we have identified from incident databases that exemplifies the safety risk of concern. Although we carry out a thorough investigation of the reference event it does not replace the local ‘SI’ investigation as our inquiry is designed to identify and confirm the nationally significant safety risks. The investigation then moves on to explore the safety risks and issues identified at a national level (i.e. policy, guidance and organisation of services etc).
Our investigations are all available on our website www.hsib.org.uk. National investigations of particular interest to ICS members may be Failure to act on unexpected radiological findings, Recognising and Responding to Critically Unwell Patients, Transport of critically ill patients and Wrong Route Medication.
From 1 April 2018, we became responsible for all patient safety investigations of maternity incidents occurring in the NHS which meet criteria for the Each Baby Counts programme. The purpose of these investigations is to identify learning and improvement in maternity services, and common themes that offer opportunity for system-wide change.
For these incidents HSIB’s investigation replaces the local SI investigation, although the trust remains responsible for Duty of Candour. We work closely with parents and families, healthcare staff and organisations during an investigation. Our reports are provided directly to the families involved and to the trust. The trust is responsible for actioning any safety recommendations we make as a result of these investigations.
We are now operating in all trusts across England, have trained 150 investigators and have commenced over 600 investigations in 18 months of operation. An amazing achievement in its own right. The volume of data is helping to identify themes to improve the provision of maternity services.
Have your say
I’m excited by the work of HSIB and the possibility to influence positive change in the NHS. We bring a new approach to safety investigation in healthcare. We value feedback on our reports and our investigations so please contact me via email@example.com with feedback, questions or safety concerns.