Types of investigations

The HSIB will investigate up to 30 cases each year based on analysis of a wide range of source material including NHS patient safety reporting, as well as information provided to HSIB by healthcare staff, organisations and the public. The decision to investigate is made based on detailed criteria and takes into account the impact, the systemic risk and the learning potential the case raises. In 2018 it also became responsible for conducting all maternity safety investigations in the NHS which meet criteria under the RCOG's Each Baby Counts programme, with the aim of achieving rapid learning across maternity services.

HSIB aims its recommendations at national organisations with the power to deliver change in systems and processes to improve patient safety. However, doctors working in services covered in an HSIB investigation may find the reports help with understanding the ways that system, organisational and human factors can impact on safe professional practice.

Portable oxygen systems

As a result of problems experienced during a resuscitation attempt where it was found that the reservoir bag attached to an oxygen cylinder was not inflating between breaths, a trust asked the HSIB to examine portable oxygen systems.

As a result of the investigation a number of safety observations and recommendations were made, including around the design of portable oxygen systems and how they are regulated by the Medicines and Healthcare products Regulatory Authority (MHRA).

Testicular torsion

An ongoing investigation into the diagnosis and management of acute onset testicular pain came about after a mother raised potential safety issues following the treatment of her son, who had an orchidectomy due to a testicular torsion. The full investigation aims to develop a greater understanding of variations in diagnosing and treating the condition as well as the impact on patients and clinicians.

Other ongoing investigations include dealing with critically ill patients, the management of chronic health conditions in prisons and the diagnosis and management of ectopic pregnancy.

Working with healthcare safety investigations

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Working with healthcare safety investigations