Healthcare Safety Investigation Branch: Reports and Recommendations

The Healthcare Safety Investigation Branch (HSIB) conduct independent investigations of patient safety concerns in NHS-funded care across England.

By meganpeng · February 2, 2021

Funded by the Department of Health and Social Care and hosted by NHS England and NHS Improvement, the HSIB aims to improve patient safety through effective and independent investigations that don’t apportion blame or liability. The safety recommendations outlined within their reports seek to improve healthcare systems and processes in order to reduce risk and improve safety.

Below is a list of published HSIB reports of note for all healthcare professionals working in paediatrics:

  • 18th October 2017: Transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS). An investigation following the case of a young person who committed suicide shortly after transitioning from CAMHS to AMHS that identifies a number of factors contributing to the event in the context of the wider healthcare system. Full report online here.
  • 14th November 2017: Inadvertent Administration of an Oral Liquid Medicine into a Vein. An investigation launched after a 9-year old child was wrongly administered an oral liquid drug into a vein during a planned renal biopsy that is classed as a wrong route medication error and defined as a ‘never event’ in the NHS. Full report online here.
  • 1st August 2018: Undetected Button/Coin Cell Battery Ingestion in Children. A review of current processes for the identification and treatment of button/coin cell battery ingestion in children under the age of five years; including management of associated non-specific symptoms when ingestion is unknown; the communication between NHS 111, primary care services, out-of-hours, acute and ambulance services; and how ambulance services assess and manage paediatric cases in relation to non-specific symptoms. Full report online here.
  • 27th June 2018: Management of Acute Onset Testicular Pain. An investigation focusing on the case of a 20-year-old student who suffered testicular torsion and lost the right testicle due to a delay in diagnosis and treatment; including review of the management of acute onset testicular pain, GP referral pathways into hospitals, the role of primary care telephone consultations, the diagnostic and treatment pathway for testicular torsion, and the possible delays and associated human factors. Full report online here.
  • 15th May 2019: Undiagnosed Cardiomyopathy in a Young Person with Autism. A review to understand safety risks associated with patients with additional needs following the death of a young person with autism spectrum disorder and an associated learning difficulty who had undergone an MRI scan under general anaesthetic and suffered unexpected deterioration caused by undetected cardiomyopathy. Full report online here.
  • 23rd January 2020: Neonatal Collapse Alongside Skin-to-Skin Contact. A national learning report to highlight the importance of clinical monitoring during skin-to-skin contact following birth and additional risk factors for sudden unexpected postnatal collapse. Full report online here.
  • 3rd February 2020: Severe Brain Injury, Early Neonatal Death and Intrapartum Stillbirth Associated with Group B Streptococcus Infection. A national learning report to highlight common patient safety themes emerging around Group B Streptococcus from initial investigations carried out as part of the Maternity Transformation Programme. Full report online here.


A number of reports investigating events around adult care also have overarching relevance to clinical practice. These include:

  • The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors in hospital in a report published in October 2018.
  • Introducing smart infusion pump technology in NHS hospitals published in August 2019.
  • Prescribing and administering insulin from a pen device in hospitals published in February 2020.
  • Outpatient follow-up appointments that are intended but not booked after an inpatient hospital stay published in February 2020.
  • Managing the risk of COVID-19 transmission in hospitals published in October 2020.
  • Placement of nasogastric tubes and how previously identified safety improvements to prevent misplacement have been implemented published in December 2020.
  • Support for staff following patient safety incidents published in January 2021.


Current ongoing investigations involving paediatric care conducted by the HSIB include:


The HSIB welcome information about NHS patient safety concerns from all healthcare professionals working in the NHS – visit the HSIB website to find out more here.