We investigate patient safety concerns across England to improve NHS care at a national level.
This report demonstrates how the Patient Safety Incident Response Framework (PSIRF) can be used to investigate patient safety incidents and identify opportunities for learning and improvement. Includes areas for improvement relevant to mental health services across England.
Patients who use online prescription services may be at risk of harm because clinicians treating them do not have access to a complete picture of their health information. We've made safety recommendations to improve how information is shared between the NHS and independent prescribers.
This report shares learning from a pilot of a new rapid investigation process that examined a redesigned regional care pathway. It warns that unclear roles, limited oversight and inconsistent information sharing can limit how risks are identified and managed across NHS organisations.
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.
We have launched a new strategy to help meet the demands of a changing patient safety landscape.
‘Building investigation excellence: our strategy for strengthening the capability of healthcare investigations’ will be instrumental in supporting investigators across the NHS in England to carry out high-quality investigations that drive real improvements in patient safety.
We would like to hear from everyone, including patients, families and NHS and healthcare staff.
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