The importance of learning: spotlight on the safety watchdog's recent reports

In the first of a series of three blogs on the importance of learning, Jill Mason explores the Healthcare Safety Investigation Branch's recent reports. 

In 2019/20 the Annual Report reveals that HSIB published 15 national reports (see list on page 24) and addressed 58 recommendations to 26 organisations and made 46 safety observations as well as 29 safety actions. The year also saw the publication of their first national learning report which summarised themes arising from their maternity programme.

They flag that to fully monitor the progress of promised measures to improve patient safety, NHS England and NHS Improvement have established a patient safety committee to allow HSIB to escalate concerns about the quality of safety recommendation responses.

Highlights from their year are set out at page 14.

A summary of each of the 15 nationals reports are set out at pages 27-40. You can read our commentary on some of these reports here

In 2020/21 they intend to thematically analyse all the national investigation reports they have published in their first three years of operation in order to publish a national learning report that will identify common themes across those investigations. This will help inform the future selection of HSIB investigations. Likewise for the maternity investigation reports – this time in order to understand common risks that require further investigation by the national team.

Interesting pie charts at pages 49 and 50 show the variety of sources of referrals into HSIB (with 29 per cent from families and 3 per cent from coroners) and the split across various care settings (with 53 per cent relating to acute care and 11 per cent relating to mental health).

One of HSIB’s strategic goals is to provide learning to the wider healthcare community and promote professional patient safety investigations by improving investigation skills and techniques throughout the NHS. During their fourth year they want to grow their education, learning and development offer. They also hope to reschedule their first International Healthcare Safety Investigation Conference. 

Their latest publication, Giving Families a Voice: HSIB’s approach to patient and family engagement during investigations will also be of interest to readers as the intention is to share HSIB’s experiences so organisations can, should they choose, understand and reflect on how HSIB’s experience may be applicable to them. Chief Investigator, Keith Conradi clearly states that including the family voice in investigations is fundamental to bringing about improvements in systems and processes to reduce risk and improve safety and, indeed, that failing to collaborate effectively with families excludes their experiences from investigations and perpetuates feelings that their voices are not heard. He goes so far as to say poor engagement may inflict further harm to families.

The report lists their five fundamental principles for effective family engagement – personalised, accessible and inclusive, open and transparent, respectful and timely. It then goes on to set out HSIB’s process for family engagement at pages 17 -25.

Page 35 sets out what HSIB would share as learning for family engagement relating to both investigators and the process and, finally, page 40 sets out what HSIB believes family engagement should involve / be / ensure.

Our content explained

Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.

Posted by


Mills & Reeve Sites navigation
A tabbed collection of Mills & Reeve sites.
My Mills & Reeve navigation
Subscribe to, or manage your My Mills & Reeve account.
My M&R


Register for My M&R to stay up-to-date with legal news and events, create brochures and bookmark pages.

Existing clients

Log in to your client extranet for free matter information, know-how and documents.


Mills & Reeve system for employees.