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Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
publishedWe are working on a report to share learning gained from our investigation activities and education programme about patient safety incident investigations under the Patient Safety Incident Response Framework (PSIRF).
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Published
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Theme:
NHS staff, Patient safety themes, Patient and family
An exploratory review of maternity and neonatal services
publishedThis report is a summary of information HSSIB collected during an exploratory review of maternity and neonatal services in spring 2025. This exploratory review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB and one report published in 2021 by the Health…
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Published
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Theme:
Maternity investigations, Neonatal
Workforce and patient safety
publishedThe workforce challenges faced by the NHS in England present a significant risk to patient safety and staff wellbeing. These investigations consider how working conditions can be optimised to support patient safety, while maintaining and improving NHS staff wellbeing.
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Published
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Theme:
NHS staff, Patient safety themes -
Awaiting safety recommendation responses
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
publishedThree reports that model investigation of sepsis under the Patient Safety Incident Response Framework (PSIRF), to boost local learning and help improve investigation quality in the NHS.
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Published
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Theme:
Delayed diagnosis, Hospital care, Patient safety themes
Mental health inpatient settings
publishedThis series of patient safety investigations look at mental health inpatient settings. They were directed by the Secretary of State for Health and Social Care. We've completed five investigations and an overarching report that explores cross-cutting patient safety risks.
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Published
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Theme:
Mental health -
Safety recommendation responses received
The impact of staff fatigue on patient safety
publishedStaff fatigue contributes directly and indirectly to patient harm. Yet fatigue is not routinely considered in patient safety event reporting or learning reviews. We share safety recommendations and learning for healthcare organisations to increase their understanding of staff fatigue. This includes…
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Published
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Theme:
NHS staff, Patient safety themes -
Safety recommendation responses received
12-lead electrocardiograms (ECGs) in ambulance services
publishedThese two investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).
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Published
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Theme:
Emergency care, Cardiac -
Safety recommendation responses received
Safety management
publishedThis investigation considers how safety management is coordinated and integrated across the healthcare system. It looks at accountability beyond organisational boundaries and involving NHS staff and patients.
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Published
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Theme:
NHS staff, Patient safety themes, Patient and family, Continuity of care -
Safety recommendation responses received
Sexual safety: the implications for patient safety
publishedThere is evidence of widespread sexism, sexual misconduct and harassment in healthcare. Between May and September 2024, we carried out exploratory work to consider the potential of conducting an investigation into patient safety risks associated with sexual safety.
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Published
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Theme:
NHS staff, Patient and family
Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare
publishedIndependent report published by the Health Services Safety Investigations Body and arm's-length body members of the Recommendations to Impact Collaborative Group.
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Published
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Theme:
Patient safety themes