New HSSIB Report focuses on medication safety after hospital discharge
The Health Services Safety Investigations Body (HSSIB) has published the third and final report in a series of investigations exploring patient safety events in NHS organisations to understand why patients may not have received medications as planned.
The particular investigation explores the systems and processes in place to support when patients are discharged into the community with medications. HSSIB’s report sets out a detailed analysis of the case a 53-year-old patient with diabetes – following issues with his insulin administration after discharge from hospital. The report concludes with comprehensive local-level learning prompts to help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The prompts cover care in hospital, discharge planning and care in the community.
Read the full report and access the local learning prompts here: Medication related harm
They have also produced a summary video: https://youtu.be/6cYw6cP77rU?si=O7iak-VvTscGiwoB
HSSIB publishes exploratory review of maternity and neonatal services
In spring 2025, the Health Services Safety Investigations Body (HSSIB) conducted an exploratory review of maternity and neonatal services. This work involved engagement with 17 key stakeholders and the review of 35 safety concerns alongside previous findings from a 2021 HSIB report. The report reiterates that challenges in maternity and neonatal safety are the result of systemic issues at a national level, rather than isolated issues within local areas.
In June, the Secretary of State for Health and Social Care announced a national investigation into maternity care. In light of this announcement, and to avoid duplication, HSSIB have currently paused ongoing investigatory work, but have shared concerns and insights from this report with the Secretary of State and teams within the Department for Health and Social Care. The report also details areas that could be considered for further investigation.
11 key themes emerging from the report
- Some progress has been made in maternity and neonatal outcomes, staffing levels and governance arrangements.
- National maternity and neonatal systems are overly complex
- National collaboration efforts are inconsistent and variable.
- Too many recommendations exist, with limited implementation.
- Local governance of maternity services often operates in isolation from host organisations.
- There is still a lack of ability for services to identify and respond to clinical risks.
- Limited potential to learn from harms that happen to women and babies during pregnancy, labour and birth.
- Patients experience compounded harm due to systemic issues, particularly local investigations or the way a complaint/concerns are managed.
- Staff are also affected by cumulative stress and harm.
- Disparities in care and outcomes persist in relation to inequalities.
- There are concerns about the standards set in undergraduate and postgraduate education and whether these can be adhered to in practice.
Read the full report: An exploratory review of maternity and neonatal services — HSSIB