Patient safety investigations

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Close-up of man with a closely trimmed beard. He takes a pill with a glass of water.

The prescribing of lithium for bipolar disorder

Around 1 in 50 adults experience bipolar disorder within their lives. Whilst the number of people with bipolar disorder has remained consistent over time the prescribing of lithium has been in decline for decades.
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Launched

  • Theme:

    Mental health, Medication
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Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

published
We 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

  • Theme:

    NHS staff, Patient safety themes, Patient and family
Young woman wearing a baggy long sleeve jumper meets with her doctor.

Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)

We have launched three investigations to provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF).
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Launched

  • Theme:

    Mental health, Hospital care, Patient safety themes
A woman sits on a sofa hugging her knees.

Safety issues for people experiencing a mental health crisis who come into contact with urgent and emergency care services

Mental health crisis describes when a person feels at breaking point and where they need urgent help. We have launched two investigations that explore the patient safety issues associated with care pathways for people experiencing a mental health crisis who come into contact with urgent and emergen…
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Launched

  • Theme:

    Mental health, Emergency care, Access to care
A male nurse kneels next to a female patient laying in a bed on a hospital corridor.

Patient care in temporary care environments

We have launched an investigation that explores the patient safety issues associated with the use of temporary care environments. For example, hospital corridors and ambulances outside emergency departments.
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Launched

  • Theme:

    Acute, Emergency care, Patient safety themes
Image shows a pregnant person holding palms in a heart shape

An exploratory review of maternity and neonatal services

published
This 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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Launched

  • Theme:

    Maternity investigations, Neonatal
A female nurse gives an older woman medical pills.

Medication related harm

published
Medication is the most common intervention for patients in the NHS. In the most serious cases, delayed and missed medication can cause catastrophic effects. We have completed three local investigations, and a national investigation is underway, looking at medication related harm.
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Published

  • Theme:

    Medication, Communication and decision making, Continuity of care
Close up of hands using a smart phone.

Online prescribing: challenges and opportunities to improve patient safety

This investigation looks at the complex regulatory landscape around independent online prescribing and challenges sharing patient information between the NHS and independent online prescribing services.
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Launched

  • Theme:

    Medication
A district nurse cares for an elderly man with a head injury in his living room at home.

Workforce and patient safety

published
The 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

  • Theme:

    NHS staff, Patient safety themes

  • Awaiting safety recommendation responses

Focus on the hand of a hospital patient laying on a bed. An IV cannula is inserted in a vein on the top of their hand.

Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)

published
Three 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

  • Theme:

    Delayed diagnosis, Hospital care, Patient safety themes
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