We investigate patient safety concerns across England to improve NHS care at a national level.
This report is a summary of information we collected during an exploratory
review of maternity and neonatal services in spring 2025 This review involved meetings with 17 stakeholders and a review of 35 safety concerns submitted to HSSIB.
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 highlight the importance of information sharing between services to ensure patients are confident in medication self-administration.
There are risks to patient safety due to poor interoperability between digital systems and challenges with GP registration in prisons. We explore how information is shared between operational and healthcare IT systems in prisons and the General Medical Services (GMS) registration process.
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.
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