HSIB Investigation report – transition from child mental health services to adult

This investigation followed the Healthcare Safety Investigation Branch being notified of an 18-year-old who died by suicide shortly after transitioning from child and adolescent to adult mental health services. The investigation identified possible issues regarding...

Updated Just Culture Guide – NHS Improvement

NHS Improvement have updated their Just Culture Guide. To download click here

HSIB first national investigation report – wrong prosthesis

The Healthcare Safety Investigation Branch (HSIB) has published its first investigation report relating to a surgical never event. The patient is a 63-year-old man who underwent hip replacement surgery. During this surgery, incompatible components were used. The error...

Draft Health Service Safety Investigations Bill

The draft bill proposes setting up the Health Service Safety Investigations Body (HSSIB). The HSSIB will conduct investigations which focus on learning from patient safety incidents in the NHS, to reduce health care harm and improve patient care. The draft bill allows...

Williams Review into gross negligence manslaughter in healthcare

The review makes recommendations to support a more just and learning culture in the healthcare system. It covers: the process for investigating gross negligence manslaughter reflective practice of healthcare professionals the regulation of healthcare professionals...

Measuring Safety Culture

This Health Foundation evidence scan provides a brief overview of some of the tools available to measure safety culture and climate in health care. Safety culture refers to the way patient safety is thought about and implemented within an organisation and the...