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HSIB’s local investigation pilot: Shared learning to help improve patient safety

The Health and Safety Investigation Branch has published the final evaluation report of its local investigation pilots into the value of investigating specific, single non-maternity patient safety events that had occurred in healthcare organisations.

The pilot investigations

The pilot investigations were designed to allow HSIB to develop and evaluate an approach for local investigations that was of value to local healthcare organisations, including the identification of new learning in relation to patient safety risks as well as insights to support local healthcare organisations processes within NHS England’s recently launched Patient Safety Incident Response Framework (PSIRF).

The pilot steering group identified ‘multi-agency safety events’ as a focus for the pilot, defined as incidents in which a patient was harmed, or had the potential to be harmed, through their care and in which multiple healthcare organisations were involved.  

The report identifies four safety observations centred on four themes: multi-agency collaboration, implementing effective actions, learning from the combining of findings, and learning from safety events regardless of severity.

Multi-agency collaboration

The report highlights the challenges faced by local healthcare organisations when investigating multi-agency safety events, due in part to the logistical difficulty of co-ordinating organisations, concerns around the independence of the investigative body, and the reluctance of any one organisation to take the lead.

Effective healthcare delivery relies upon integrated process across multiple organisations and the report emphasises the need for safety investigations to understand the factors that contribute to events along care processes. The report concludes that it may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the PSIRF.

Implementing effective actions

The report notes mixed perspectives from stakeholders on the ability of local healthcare organisations to develop and implement actions that would bring about sustained improvements in patient safety. 

The feedback on the safety recommendations made by the HSIB as part of the pilot investigation demonstrates the need to support healthcare organisations with development of effective actions in response to recommendations of the HSIB.

Safety action generation is considered in the latest PSIRF and the report concludes that it may be beneficial for national and regional bodies to consider how healthcare organisations can be supported to develop effective systems-based solutions to identified patient safety risks.

Combining findings to improve learning

Healthcare safety investigations generally identify learning within the context of the specific safety event being analysed. Where investigations are considered in isolation this may prevent the generalisation of findings and limit their wider impact on effective healthcare provision. The report highlights the benefits of combining the findings of multiple investigations to identify recurrent factors that pose risks to patient safety.

The combining of findings from multiple local investigations affords an opportunity to identify themes for future safety improvements across healthcare systems and to make national safety recommendations. 

Two such examples from the pilot investigations include the inconsistent use of the unique NHS patient identification number, putting patients at risk of harm due to receiving incorrect treatment, and delays to the handover of patients from ambulances to emergency departments, putting patients at risk of harm due to delays in care. 

The report concludes that it may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.

Learning from safety events regardless of severity

Investigations into patient safety events traditionally focused on events where harm has occurred. 

However, patient safety events where limited or no harm occurs may still afford valuable insights and learning can and should be taken from these events. 

This is learning that would otherwise have been lost and may contribute towards actions that will prevent future harm. 

The report concludes that it may be beneficial for providers of NHS care to consider low-harm and no harm safety events as sources of learning in local patient safety incident response plans.


 Developing effective actions locally can be challenging for many reasons, including limited capability and capacity of local healthcare authorities to conduct their own investigations and the need for investigations to be conducted independently.

The report highlights that significant learning can be taken from local investigations by a national body such as the HSIB into individual multi-agency patient safety events, and that findings of national value may be drawn from an evaluation of the localised provision of healthcare. 

It's hoped that the findings set out in the report are incorporated by policy makers to improve patient safety outcomes at both the local and national level.

Find out more about Irwin Mitchell’s expertise in supporting patients and families affected by care issues at our dedicated medical negligence section.