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We investigate patient safety concerns across England to improve NHS care at a national level.
This report brings together common themes from our series of mental health investigations, plus new findings. Recommendations to improve inpatient services are too often not implemented, which leads to missed opportunities to learn, improve and prevent harm to patients and NHS staff.
Staff 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.
During our investigation we found there is a considerable burden placed on patients and their loved ones to co-ordinate their care. Our safety recommendations aim to ensure that patients have co-ordinated care plans with effective communication between services and a single point of contact.
We aim to be the global leader in professional, high quality healthcare safety investigations. We investigate patient safety concerns across England to improve NHS care at a national level. Our investigations do not find blame or liability with individuals or organisations. Information shared with us is confidential and protected by law.
We are a fully independent arm’s length body of the Department of Health and Social Care.
We can investigate patient safety concerns that occur in England during the provision of healthcare services, and that have or may have implications for the safety of patients.
Our investigations can consider healthcare provided in the NHS and the independent sector. Where an investigation relates to an incident that did not occur in the NHS, we must consider whether NHS systems and practices could be improved because of our investigation.
We can also be directed to investigate a patient safety concern by the Secretary of State for Health and Social Care.
Our CPD accredited education programme is delivered by healthcare safety investigation experts.
We offer a range of courses to support development and help embed professional safety investigations across the NHS. For NHS staff in England, courses run online and are free of charge to attend. Courses are also available to fee paying learners outside of the NHS in England.
Our flagship course – A systems approach to investigating and learning from patient safety incidents – launches new cohorts throughout the year.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
Share a concern