• There are no core national patient safety standards that inform either the design or procurement of ePMA. This can lead to unwarranted variation in functionality across and between ePMA, other electronic systems, and acute hospital trusts, which may pose challenges for staff when prescribing and administering medication.
• Current assurance mechanisms do not provide national oversight or enforcement of either manufacturer or healthcare provider compliance with legally mandated standards relating to digital clinical safety and interoperability of digital health technology.
• The safety risks associated with software such as ePMA are complex and may change rapidly. Legislation, regulation and standards may not keep up with the speed of technological change.
• Manufacturers must self-assess and report whether their ePMA is compliant with relevant standards for their products to be included on an NHS procurement framework.
• There is variation in the core safety standards identified by acute hospital trusts when procuring and contracting for ePMA functionality. This leads to trusts identifying safety requirements individually, with limited consistency in the approach taken across trusts.
• Reliance is placed on acute hospital trusts to determine whether ePMA manufacturers have interpreted the medical device regulations appropriately, and to assure themselves that the trust complies with relevant standards. Some trusts do not have the resources, skills and expertise to do this effectively.
• Digital safety and patient safety teams at local and national level may work in silos, with limited ability to share information or collaborate on ePMA-related decisions that impact on patient safety.
• There are challenges with identifying national safety learning relating to ePMA as this is not reliably captured, shared or identified through formal reporting routes. There is ongoing work to improve the NHS reporting system to capture digital-related patient safety incidents.
• There is a reliance on informal networks for sharing ePMA safety issues which means safety concerns may not always be shared with those who need to be aware.
• Some ePMA manufacturers, whose ePMA functionality is not registered as a medical device choose to apply equivalent governance and assurance measures as if it is a medical device. This is in addition to complying with the digital clinical safety standard (DCB0129).
• Acute hospital trusts face challenges prioritising and resourcing procurement decisions for ePMA functionality. This leads to challenges and patient safety issues when ePMA is implemented.
• Clinical safety officers (CSOs) may not be adequately resourced, meaning they have limited capacity to support in managing clinical risks associated with ePMA.
• There is variation in how the CSO responsibilities set out in the digital clinical standards are interpreted and implemented by trusts. NHS England is working on plans for a formal curriculum and potential accreditation to improve CSO skills and capabilities.

HSSIB makes the following safety recommendations

Safety recommendation R/2026/086:

HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that:

• routes for manufacturers and healthcare organisations to engage with them are clear and accessible
• it reviews and provides further guidance and clarification on when electronic prescribing and medicines administration (ePMA) software should be considered a medical device.

This will support how ePMA software can be appropriately classified and regulated to improve patient safety.

Safety recommendation R/2026/087:

HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in the safety of ePMA functionality.

Safety recommendation R/2026/088:

HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance processes.

Safety recommendation R/2026/089:

HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to:

• supporting healthcare providers to access digital clinical safety knowledge, capacity and capability
• integrating digital clinical safety and patient safety, including the associated terminology
• supporting robust assurance of whether electronic prescribing and medicines administration (ePMA) manufacturers comply with relevant standards in order to be considered for inclusion on an NHS procurement framework.

This will support effective decision making and oversight by acute hospital trusts and reduce unwarranted variation in the understanding of, and approach to, adopting ePMA.

Safety recommendation R/2026/090:

HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to ensure oversight of ePMA functionality to improve patient safety.

HSSIB makes the following safety observations

Safety observation O/2026/086:

Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality.

Safety observation O/2026/087:

Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.

Safety observation O/2026/088:

Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.

• embedding explicit consideration of racism within investigation standards
• improving expectations for family involvement
• strengthening leadership accountability for equity
• ensuring more consistent use of data to identify inequalities
• anti-racism to be a core component of patient safety investigations
• robust mechanisms to monitor implementation and impact.

• People with diabetes (who require insulin) are at risk of harm through the administration of insulin when pre-existing or new disabilities/impairments have not been recognised or adjusted for.
• People are not always empowered to become competent to manage their insulin, with assumptions made that a person is not competent to do so because of a disability/impairment.
• Supporting people to safely self-manage their health, including insulin, requires integrated working across community services. Where this is limited, such as due to resource challenges or limited collaboration, people are put at risk.
• Efforts to empower and enable people to self-manage insulin are affected by the competing demands on, and the capacity and accessibility of the community services that provide this type of support.
• Designated and protected resource aimed at supporting the development of insulin self-management skills have shown benefits for patient experience and have reduced demand on community services.
• There is no national competency framework for the management of insulin by patients and families that supports community services to identify and make reasonable adjustments for a disability/impairment.
• Administration of insulin by staff in care homes (delegated administration) may reduce demand on community teams but is limited by barriers to implementation, including high turnover of care home staff.
• Some people with type 2 diabetes may be prescribed insulin without first optimising other diabetes treatments and/or exploring preferences. This means a person may be exposed to the risks of insulin unnecessarily.
• There are people with diabetes (who require insulin) whose circumstances mean they are not monitored for changes in a disability/impairment, including via long-term condition reviews in general practice.
• People may not engage with healthcare services to enable the regular monitoring of their condition. Engagement is affected by the ability of services to meet patient needs but may also represent other situations that require a response, such as in relation to patient safeguarding.
• Electronic systems in general practice may not alert users when people have not requested repeat prescriptions of insulin, removing a potential opportunity to identify patients who need support.
• Diabetes technology, such as insulin pen devices, are not always designed in a way that supports people to administer insulin when they have a disability/impairment, such as visual impairment or problems with dexterity.
• There are concerns about the future competence of the healthcare workforce to support the increasing numbers of people with hybrid closed loop systems.
• Healthcare workers may not identify when a patient’s mental capacity to make decisions in relation to their insulin may be compromised, meaning a more in-depth assessment in line with the Mental Capacity Act (2005) may not occur.
• Limited education and practical support for application of the Mental Capacity Act (2005) by healthcare staff means its principles are sometimes misunderstood.
• Patients with diabetes (who require insulin) and who experience fluctuations in their mental capacity, are at risk of harm when services do not proactively plan for a time when the patient may lose the ability to manage their insulin safely.

HSSIB makes the following safety recommendations

• HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is to support recognition of models that have safely, effectively and equitably engaged patients, their families and carers, including through the use of modern diabetes technology for self-management.
• HSSIB recommends that NHS England/Department of Health and Social Care develops a tool for use in community settings to support the assessment of competency of patients, their families and carers to manage and administer insulin and care for people with diabetes. This should include recognition of a person’s circumstances, the impact of disabilities and impairments, and potential adjustments to support administration where safe to do so. This is to support consistency in how competency is assessed for the safe management of insulin within the context of modern diabetes care.

HSSIB makes the following safety observation

• National bodies can improve patient safety by providing clarity on expectations around 1) how staff recognise that a patient’s mental capacity may be compromised in relation to decisions about their self-management of insulin, and 2) the undertaking of a mental capacity assessment by the most appropriate person. This should include clarification on the practical application of the Mental Capacity Act (2005) to situations where a patient’s capacity may fluctuate and where sharing confidential information to support patient safety may be appropriate.

HSSIB suggests safety learning for integrated care boards

• HSSIB investigations include safety learning for integrated care boards where this may help organisations think about how to respond to a patient safety issue that relates to integrated care across a geographical footprint. Informed by the findings in this report, the investigation proposes the following safety learning.
• HSSIB suggests that integrated care boards develop data-driven approaches to effectively identify the diversity of their populations’ characteristics and social circumstances, and use this data to support community providers to design services that empower and enable people to be involved in a patient’s care, including through supporting self-management of medications and conditions.
• HSSIB suggests that integrated care boards, through future planning for neighbourhood health services, include consideration of how patients who may be at greater risk of harm from insulin administration due to their specific circumstances – for example co-existing disabilities, social isolation or receiving home-delivered medications – are proactively monitored to identify changes in their circumstances. This may include using technology such as remote monitoring.

Local-level learning

HSSIB investigations include local-level learning where this may help providers/organisations respond to a patient safety issue at the local level. Informed by the findings in this report, the investigation shares the following local-level learning.

• How does your organisation create the conditions for staff to empower and enable patients, their families and carers – through a person-centred approach – to self-manage insulin where appropriate?
• How does your organisation proactively identify the varying needs of people with diabetes in its local population, and ensure these are met to enable their management of insulin?
• How does your organisation promote patient-centred care and facilitate self-care models that empower and enable patients, such as those with diabetes?
• Does your organisation allocate specific resources to support patients, families and carers to develop competency to self-manage insulin, and ensure those resources are protected to empower and enable people?
• How does your organisation ensure that staff supporting the development of a person’s competency have the required knowledge and skills to provide that training and education in relation to diabetes and insulin?
• How does your organisation support staff to identify and code a person’s disabilities/impairments that may influence their competency to self-manage insulin, and ensure these are considered and adjusted for when deciding whether a person is competent?
• Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances?
• How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions?
• How does your organisation identify and code patients – who may be more vulnerable to harm from insulin due to their circumstances – for increased monitoring? This may include patients who have their medications delivered to their home, who do not have family nearby, or who are housebound.
• Does your organisation provide practical training and guidance to support staff to consider the mental capacity of patients to make decisions around their insulin when there are concerns capacity may be compromised?
• Does your organisation provide practical guidance to staff to help identify when it is lawful, ethical and appropriate to share confidential information about a patient to mitigate risks to their safety, including with family members?
• Does your organisation have accessible routes via which staff can seek urgent support when they are concerned a patient’s mental capacity to make decisions about their self-care may be compromised, particularly in high-risk situations?
• How does your organisation support staff to develop ‘crisis plans’ for patients who self-manage insulin to protect their safety at a later point when their capacity to make decisions in relation to their care may change?

The investigation found that:

• The Service User’s attempt to end his life was not expected by the mental health staff supporting him.
• The change to his medication meant it was a potentially vulnerable time for the Service User's mental health. This was despite him having a safety plan for how to seek help if he felt overwhelmed and planned monitoring check-ins in line with local procedure.
• The Service User’s case was complex and challenging; his mental ill-health, drug and alcohol use are likely to have impacted on his ability to reason and make informed decisions. Therefore, sharing of information across and between healthcare services was important to facilitate personalised care planning.
• Limited sharing of, and lack of ready access to, information about the Service User and his past mental health history impacted on the CMHS’s ability to provide effective and timely care.
• The Service User needed a tailored approach with reasonable adjustments to maximise his engagement with mental health services; there was a delay in his needs being identified and acted on.
• There was limited understanding and awareness by some staff of whether mental health medication can be offered to service users with mental health issues and concurrent alcohol use.
• Staff worked in a service that was overstretched and they had to make decisions about managing service user needs, service demand, and risk and safety, within limited resources. The demand for CMHT services exceeded the available capacity, impacting both service users and staff.
• Staff did not have the dedicated time and space to process and deal with distress they encountered as part of their daily work caused by incidents of patient harm.
• There are challenges to delivering the national ambition to provide a community focused model of care, many of which the mental health trust has limited or no control over.

Summary of areas for improvement

The investigation identified four areas of improvement which the mental health trust could develop safety actions to address.

Area of improvement 1: Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.

Area of improvement 2: Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.

Area of improvement 3: Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.

Area of improvement 4: Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.

It is reported that around 3% of all ED attendances are mental health related. However, people experiencing mental health problems are twice as likely as other patients to remain in the ED for more than 12 hours.

People in mental health crisis may need to be assessed for admission to a mental health hospital in line with the Mental Health Act 1983. Delays in these assessments being undertaken, and/or the lack of availability of mental health inpatient beds once a person has been recommended for admission, can lead to patients remaining in EDs for prolonged periods.

Findings

• There is an absence of clear legal powers to lawfully prevent vulnerable individuals from leaving the ED while awaiting assessment or admission.
• This legal ambiguity exposes patients to increased risk of harm and/or being unlawfully deprived of their liberty, and places staff in a position of uncertainty when attempting to manage safety.
• For those requiring formal admission to a mental health hospital, an application under the Mental Health Act 1983 cannot be completed until a bed has been identified, which can take days.
• Staff and organisations reported they are often faced with choosing “the least harmful way to break the law” in order to try and keep patients safe.
• EDs are not designed to provide therapeutic mental health care and prolonged stays may worsen patients’ conditions and create challenges in maintaining a safe environment for everyone.

HSSIB makes the following safety recommendations:

• HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health professionals to hold someone in the emergency department. This will safeguard people who are currently arriving at the emergency department in a mental health crisis and the staff who care for them to support safe, consistent and legally compliant care.
• HSSIB recommends that the Care Quality Commission works with stakeholders to produce a position statement on existing legal powers, and the expectations for support for staff, for the care of people experiencing a mental health crisis in emergency departments (including mental health emergency departments and mental health crisis assessment services), who are not detained under a formal legal framework. This should include a review of current guidance and existing powers to help support safe, consistent, and legally compliant care in the absence of comprehensive legislation, while minimising harm and addressing the unique challenges of prolonged stays in the emergency department.

The investigation explored two main themes: health needs assessments and access for physically disabled people within prisons. These themes were identified during the evidence gathering phase for the three previous HSSIB reports in this series.

The findings have been separated into these two themes and are listed below:

Health needs assessments (HNAs)

• The current process of developing an HNA for a prison population, which are generally conducted at most every 3 years, means that HNAs are frequently out of date by the time they inform commissioning decisions.
• There is often a delay in prison healthcare providers being made aware of likely changes to the prison population by HM Prison and Probation Service (HMPPS). This can impact on providers’ ability to ensure the required healthcare provision is in place to serve the new population.
• Outdated HNAs lead to mismatched healthcare provision, forcing providers to submit business cases for additional services or absorb the financial impact of changes to their services.
• The business case processes were slow and did not support the needs of a rapidly changing prison population, resulting in services that may pose patient safety risks due to mismatched healthcare services, incorrect staff skill mix requiring retraining, recruitment, and removal/addition of new services.
• HNAs were commissioned by NHS England regional commissioning teams and did not include social care requirements as this is commissioned by local authorities, which made planning and provision of social care difficult and often resulted in delays in care.
• In response to limitations in the current HNA process, some regions had introduced alternative approaches, including digital data dashboards and artificial‑intelligence‑enabled tools.
• Different approaches to assessing healthcare requirements for prison populations contributed to variation in how healthcare services were commissioned and delivered across the prison estate.
• Stakeholder engagement in assessing prison population health requirements was limited; local authorities and other relevant bodies were rarely consulted, contrary to guidance.

Physical disability access

• Wheelchair users experienced harm and dignity concerns, including injuries from unsafe chair-to-chair transfers and deteriorating mental health caused by being housed in inappropriate accommodation.
• The number of wheelchair users in prisons is increasing, and many prisons cannot easily accommodate wheelchair users or people with mobility issues.
• None of the prisons visited had enough wheelchair-accessible cells. In some regions there were none.
• Accessible cells are sometimes located only on vulnerable prisoner wings, potentially wrongly associating wheelchair users with that cohort of prisoners.
• The current system for gathering information on the physical accommodation needs of people in prison is ineffective; this can impact on the ability to place people in appropriate accommodation.

HSSIB makes the following safety recommendations

• HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is to ensure that healthcare commissioners and providers can plan for changes to healthcare services that are necessary to meet the changing needs of the prison population.
• HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the needs of people in prison and prevent possible delays in care.
• HSSIB recommends that HM Prison and Probation Service reviews and amends its information gathering processes for accommodation requirements for wheelchair users and people with mobility issues, to identify and mitigate risks for people whose accommodation does not meet their needs. This is to enable and support the effective identification of appropriate prison accommodation for these groups.

• Integrated care board (ICB), regional and national oversight for inpatient diabetes care is fragmented, and assurance for patient safety is devolved to individual trusts. This leads to gaps in responsibility and accountability for implementing national guidance and recommendations, and for acting on national audit data, for improvement of patient safety.
• Regulatory activity requires strengthening to effectively assess and address safety concerns relating to inpatient diabetes care.
• Local hospital oversight structures required by national guidance and recommendations, such as diabetes safety boards, are often absent. This can hamper local-level oversight and mitigation of risks, increasing risks to inpatients who have diabetes.
• Prioritisation and funding of inpatient diabetes care at the hospital and ICB level has not supported the full implementation of national guidance and recommendations.
• Participation in the National Diabetes Inpatient Safety Audit is low, limiting the ability to track trends, benchmark performance, or drive strategic and nationwide diabetes care improvements.
• Most inpatient diabetes care is delivered by non-specialists who may lack confidence and/or competence in diabetes management.
• Specialist diabetes teams are often under-resourced and unable to provide 7-day coverage to support non-specialist staff and care for patients. Even at recommended staffing levels, specialist teams cannot always see every patient who may need support.
• Diabetes/insulin awareness training for non-specialist staff and students is inconsistent. Education gaps persist at both trust and undergraduate levels, with no national minimum mandated standard for diabetes care or insulin safety education, training and competency assessments.
• Many hospital clinicians, along with national stakeholders, strongly support adding blood glucose levels to the National Early Warning Score (NEWS2) to improve the detection of diabetes-related patient deterioration, but acknowledge challenges in doing so.
• Many patients who safely self-administer insulin at home through injection, insulin pumps, or hybrid closed loop systems, are prevented from doing so in hospital. This can be due to local policies on diabetes self-management and insulin self-administration, and the reluctance of staff to allow patients to self-administer because they fear being blamed if things go wrong.
• Lack of clarity about safe bedside storage of insulin and misconceptions about the regulatory stance on this create barriers for patients to self-administer.
• Networked glucose meters can improve safety, but implementation of required hardware and software is inconsistent.
• There is limited integration between hospital networked glucose meters and electronic patient records, creating potential blind spots in inpatient diabetes care.

HSSIB makes the following safety recommendations

• Safety recommendation R/2026/076: HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing functions (Getting It Right First Time and the Diabetes Care Accreditation Programme), and those currently in development (new National Diabetes Audit for Inpatient Care) can be more closely aligned and utilised to help better understand and respond to challenges relating to the safety and quality of inpatient diabetes care.
• Safety recommendation R/2026/077: HSSIB recommends that the Royal College of Physicians reviews and acts on new data and outcomes of studies about adopting blood glucose into NEWS2 and shares any decisions it makes. This is to encourage understanding and support consideration of how blood glucose issues can be recognised early and escalated to mitigate harm.
• Safety recommendation R/2026/078: HSSIB recommends that the Care Quality Commission assesses how it can use data from the Diabetes Care Accreditation Programme and the new National Diabetes Audit for Inpatient Care as part of its regulatory activity. This is to ensure that known challenges in inpatient diabetes care, and knowledge of providers that do not report national diabetes audit data, are considered to provide intelligence in support of regulatory activity.

HSSIB makes the following safety observations

• Safety observation O/2026/083: Organisations and individuals involved in the provision of clinical undergraduate and pre-registration education, and trust preceptorship/induction programmes, can improve patient safety by using the findings of this report to prioritise diabetes care and insulin management education and training as appropriate.
• Safety observation O/2026/084: Professional regulators and royal colleges can improve patient safety by reviewing this report and disseminating appropriate communications to their registrants and members in relation to understanding their expectations in providing safe diabetes care.

HSSIB suggests safety learning for integrated care boards

HSSIB investigations include safety learning for integrated care boards where this may help organisations think about how to respond to a patient safety issue that relates to integrated care across a geographical footprint. Informed by the findings in this report, the investigation proposes the following safety learning.

• Safety learning for integrated care boards ICB/2026/016: HSSIB suggests that integrated care boards consider the findings of this report to inform funding prioritisation decisions for trust diabetes specialist inpatient services. This is to help support the delivery of safe inpatient diabetes care through appropriately staffed 7-day inpatient diabetes specialist services to mitigate patient harm.

Local-level learning

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. HSSIB has developed the following prompts to support local-level learning for NHS trusts.

Self-management of diabetes and insulin administration

• Do you have a policy that supports patients to safely self-manage their diabetes and support self-administration of insulin?
• Is your policy clear, available, and does it enable clinicians to support safe self-management and self-administration?
• Are the timing and content of meals considered in support of patients self-managing their diabetes?
• Is safe bedside storage of insulin provided to support self-administration? If not, how could this be supported?
• Are clinicians aware of national guidance and the regulatory stance regarding promotion of safe self-management of diabetes and insulin administration?

Diabetes specialist workforce and capacity

• Is your inpatient diabetes specialist team appropriately resourced to help mitigate known diabetes-related risks?
• Is your diabetes inpatient specialist team supported to operate out of hours, such as over weekends and bank holidays?

Non-specialist diabetes care

• Do you protect education and training time for diabetes training?
• Does your diabetes training ensure key risks to inpatients with diabetes are highlighted to staff?
• Do you have a diabetes specialist team that is appropriately resourced with sufficient capacity to deliver diabetes education and training?

Hospital diabetes technology

• Do you have networked glucose meters to support remote monitoring of patients with diabetes?
• Do the glucose meters in your hospital automatically upload data to electronic patient records, and does this support remote monitoring of patients? Does your inpatient diabetes specialist team access diabetes related reports/alerts daily to identify patients at risk?
• Do you provide digital tools or apps to support your non-specialist clinicians in providing safe diabetes care?

Wearable diabetes technology

• Do you have a wearable diabetes technology element in your diabetes education and training programme?
• Do you have clear and available guidance on wearable diabetes technology for your non-specialist clinicians?

Oversight and governance

• Do you participate in the Diabetes Care Accreditation Programme (DCAP)?
• Do you submit data to the National Diabetes Inpatient Safety Audit (to be superseded by the National Diabetes Audit for Inpatient Care)?
• Do you have a diabetes safety board with senior management involvement?
• Does your diabetes safety board work with your inpatient diabetes specialist team to understand key diabetes risks and issues?
• Does your diabetes safety board have the authority to agree actions and prioritise resources for their implementation?

1. Targeted capability building – proactively direct support where the gaps in investigation capability are greatest or where it aligns with investigation priorities. For example: rather than waiting for applications for courses, HSSIB could identify sectors, organisations or cohorts of providers that would benefit from intensive support.
2. Accessible resources – the aim with this is to ensure that alongside targeted support, HSSIB provide accessible resources, and this could look like: developing online modules, toolkits and guides, as well as signposting to other resources to increase collaboration
3. Professional leadership – to enhance the developing field of healthcare investigation and to link up and connect investigators in the absence of a professional association.
4. National system convening – this is aimed at co-ordinating national efforts to build the capability of healthcare investigators to reduce duplication and aligned priorities particularly in the light of healthcare restructuring.

The strategy also focuses on establishing wider partnerships, noting the healthcare system already has considerable expertise, infrastructure, and established relationships.

Findings related to collaboration between mental health and specialist diabetes services

• Patients with a mental health problem and diabetes (requiring treatment with insulin) in the community are not always under the care of specialist diabetes services when this would be expected in their care (for example patients with type 1 diabetes).
• Patients have been discharged from specialist diabetes services after missing one or more appointments (‘did not attend’). Patients may be discharged without consideration of their circumstances and clinical risk.
• Patients have disengaged from specialist diabetes services when adjustments have not been made for their mental health needs. Services had limited access to support from specialist mental health teams.
• Community mental health teams feel responsible for their patients’ diabetes care when they are not under the care of a specialist diabetes service. Teams have limited routes through which to access support around insulin management.
• There is variable integration of mental health and specialist diabetes services in different parts of the country. This is despite recognition of the disconnect between services and the risks to patient safety and physical health.
• Digital integration between mental health and specialist diabetes services is also variable. This has created barriers to information sharing and has contributed to patient safety incidents.
• Integrated care boards face barriers – such as resource limitations, workforce shortages and separated policy teams – to developing integrated arrangements between mental health and specialist diabetes services.
• There are unclear national plans for the long-term integration of mental health and physical health services, with limited national collaboration between relevant policy teams to address the issues.
• There continues to be no effective mechanism to allow regulatory oversight of care pathways that span different providers/organisations, such as for integrated mental health and diabetes care.
• The combination of type 1 diabetes and disordered eating (T1DE) contributes to significant patient harm. There are varying views about whether T1DE is a specific condition, and research gaps around the identification of and care for patients with T1DE.
• Long-term funding for T1DE services is at risk due to factors including their cost, highly specialist nature and concerns about limiting access to services for other people with diabetes and a mental health problem.
• People experiencing homelessness face challenges accessing the support they need for their mental health and diabetes. Limited data on the need for services influences investment, and prejudice may be a factor.

Findings related to access to insulin devices and technology

• There are no insulin pen devices designed in such a way that would prevent a patient from intentionally self-administering excess insulin.
• Limitations in data collected by manufacturers and national organisations means the patient safety issue in this investigation may not be apparent to manufacturers.
• Changes to insulin pen device design in response to patient safety issues may not be considered when the issues have arisen through use of the device outside of its intended purpose.
• Some patients may be being disadvantaged by not being considered for continuous glucose monitoring or hybrid closed loop systems due to their mental health problem.

Findings related to care for patients experiencing a mental health crisis

• Community mental health teams face barriers that prevent them from forming therapeutic relationships with patients and therefore the making of safety plans should the patient feel the urge to self-harm.
• People with a diagnosis of personality disorder face challenges accessing specialist mental health services that are able to meet their specific needs.
• Mental health teams may not fully recognise the risks of self-harm associated with access to different types of insulin. This is not consistently covered in pre-registration mental health practitioner training.
• Care planning does not always consider the safeguarding of patients who experience rapid and extreme fluctuations in their emotions and mental capacity, placing them at risk of self-harm.
• Information supportive of a patient’s safety may be withheld from their family – as a result of the patient declining sharing – without staff considering the context, and the patient's mental capacity and whether they recognise the potential benefits and risks of the decision.

HSSIB makes the following safety recommendations

Safety recommendation R/2026/073:

HSSIB recommends that NHS England/Department of Health and Social Care develops a strategy for improving collaboration between mental health teams and specialist diabetes services, that includes consideration of responsibilities for integrated working at national, regional and local levels. This is to support future integration of services that will benefit all patients with mental health and diabetes care needs, including patients who are required to self-administer insulin and patients with type 1 diabetes and disordered eating.

Safety recommendation R/2026/074:

HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders:

1. maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation)
2. assesses the priority and feasibility of commissioning research to help address those gaps.

This is to help develop new knowledge to inform future decisions for the delivery of safe and effective care for this group of patients.

Safety recommendation R/2026/075:

HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that:

1. supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and
2. identifies associated care responsibilities for providers of mental and physical health services.

This is to help improve the NHS’s recognition of patients who are affected and to support decisions around the commissioning of services.

HSSIB makes the following safety observations

Safety observation O/2026/081:

Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with diabetes, and the risks that the use and misuse of insulin can present for patients with a mental health problem.

Safety observation O/2026/082:

Organisations involved in the manufacture of insulin pen devices used by the NHS can improve patient safety by:

1. understanding where devices are being used outside of their intended purpose
2. exploring the potential to design devices that would reduce the risk of intentional overdose of insulin for self-harm.

HSSIB suggests safety learning for integrated care boards

HSSIB investigations include safety learning for integrated care boards where this may support the response to a patient safety issue across a geographical footprint.

Safety learning for integrated care boards ICB/2026/014:

HSSIB suggests that integrated care boards formalise collaborations between mental health and specialist diabetes services in their local systems. Through co-production with people with lived experience, this should look to include:

• care arrangements for people with a mental health problem and diabetes, particularly for those who require insulin
• routes for community mental health teams to access advice where their patients have diabetes and access to insulin
• routes for diabetes specialist teams to seek advice from mental health teams about reasonable adjustments for patients under the care of outpatient clinics
• enablement of interoperability between electronic systems to support information sharing.

Safety learning for integrated care boards ICB/2026/015:

HSSIB suggests that integrated care boards develop data-driven approaches for the understanding of local need to inform decisions about services for patients who have been identified as marginalised in this investigation. These are patients with:

1. co-existing mental health and long-term physical health needs (diabetes), including those with a diagnosed personality disorder and/or experiencing homelessness
2. type 1 diabetes and disordered eating.

Local-level learning

HSSIB investigations include local-level learning where this may help providers/organisations respond to a patient safety issue at the local level.

For organisations providing mental health and/or specialist diabetes services:

• Does your organisation have a specific job role with responsibility for cross-organisational care pathways to ensure the holistic needs of patients, including those with mental health problems and diabetes, are met?
• How does your organisation ensure information about patients is available to other providers of care when required, for example to mental health teams about a patient’s diabetes care?
• How does your organisation ensure staff are aware of their responsibilities to report incidents associated with diabetes medication and technology, including to manufacturers and the Medicines and Healthcare products Regulatory Agency?
• Does your organisation have a process for identifying and appropriately supporting patients with type 1 diabetes who also have evidence of disordered eating?

For organisations providing specialist diabetes services:

• How does your organisation ensure patients with a mental health problem are not being discharged from clinics following a ‘did not attend’ without consideration of their circumstances and risks to their safety?
• Do your staff recognise the need to make reasonable adjustments for patients, including for those with a mental health problem, to support access to care?
• Does your organisation have a liaison psychiatry service that supports inpatient and outpatient services for people with a mental health problem?
• Does your organisation have clear routes via which services can seek support from specialists in mental health if a patient is found to be experiencing a crisis?
• How does your organisation identify patients who have had recurrent admissions with diabetic ketoacidosis or hypoglycaemia, and support staff to consider whether these patient require input from mental health services?
• How does your organisation ensure patients with a mental health problem, who meet the criteria for diabetes technology, are receiving support to access it and are not being discriminated against because of their mental health problem?

For organisations providing mental health services:

• How does your organisation ensure staff working in the community have access to advice about a patient’s physical health, including specialist advice for conditions such as diabetes requiring treatment with insulin?
• How does your organisation keep staff up-to-date about the different types of insulin used in the NHS and their onset times to ensure this is considered as part of assessment of a patient’s risk of self-harm?
• How does your organisation enable staff to work therapeutically with patients to support them to develop safety plans which include consideration of the risks associated with insulin?
• How does your organisation support multidisciplinary discussion in discharge planning that recognises the circumstances a patient is being discharged into to ensure they are appropriate for their mental and physical health needs?
• How does your organisation support staff to make assessments under the Mental Capacity Act, with particular consideration of whether the patient can use and weigh information as part of their decision making?
• Does your organisation provide services that effectively meet the needs of people with rapidly fluctuating and extreme emotions, and that consider how best to support these patients when they are unable to make decisions to keep themselves safe?
• Do your staff recognise the importance of family involvement in patient care, and where the patient refuses this, do staff ensure the reasons for refusal and the potential ramifications are explored and it is appropriately revisited over time?
• How does your organisation support staff to not make assumptions about patients based on their circumstances and characteristics?

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could help to improve NHS care.

Their latest report, Patient care in temporary care environments, provides a safety observation and learning prompts for organisations to consider when using temporary care environments. In this article we will use the more commonly known description, ‘corridor care’.[1] By this we mean care being provided to patients in corridors, non-clinical areas or unsuitable clinical areas because of a lack of hospital bed capacity.

Patient Safety Learning has raised many safety concerns about corridor care, so we  welcome HSSIB undertaking this investigation. We contributed to this report during its consultation stage, and in this article, we set out our reflections on the findings.

HSSIB report

Corridor care is becoming normalised in the NHS. The persistence of this is well documented, both in ongoing media coverage and more detailed assessments from organisations such as the Royal College of Nursing (RCN), Royal College of Emergency Medicine and the All-Party Parliamentary Group on Emergency Care.[2] [3] [4] [5] At Patient Safety Learning in the past year we have also been highlighting the key patient safety issues associated with this in a series of blogs on the hub.

This new report from HSSIB provides further evidence of the ongoing challenges posed by corridor care in the NHS. Their investigation specifically looked at acute hospitals in England and highlighted a range of risks to patient safety, including:

• Increased infection risk.
• A lack of piped oxygen and suction.
• Insufficient staff for satisfactory staff-to-patient ratios.
• Compromised response to medical and fire emergencies.
• Difficulties in monitoring patients and recognising deterioration.
• Increased risk of pressure damage or falls. They point to this particularly in the case of frail and older patients who may be located in a space that is out of direct sight and without a call bell.
• An increased risk of delirium, in particular for older patients who may find a temporary care environment disorientating.
• Specific to mental health patients, the increased risk that they may be able to abscond or access items for self-harm due to limitations in visibility in some environments.

Following on from their investigation findings, HSSIB make the following safety observation:

“NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and impact on patient safety.”

Their report includes a series of local-level learning prompts for acute hospitals. These are intended to help organisations and staff identify and think about how to respond to specific patient safety concerns related to corridor care.

Patient Safety Learning’s reflections

We believe that corridor care should be avoided whenever possible. Even in the context of the ongoing immense pressures being faced by the health service, this should not be normalised. In situations where this is unavoidable, there clearly needs to be guidance and safeguards put in place to minimise risks as far as possible. We do not think care in this physical context can ever really be characterised as good quality care.

Looking at the findings of HSSIB’s latest report, we would highlight the following issues for consideration:

1. Board oversight

We welcome the inclusion by HSSIB of local-level learning prompts in this report to help acute hospitals proactively engage with the risks associated with corridor care.

We would emphasise that in following such prompts, it is also important that there is clear oversight and leadership at Board level of these issues. This could entail designating an executive lead to coordinate the oversee corridor care. This would allow for regular reporting to the Board on this issue, including the sharing of information on incidents of patient harm associated with corridor care. This high-level organisational engagement is vital in our view. Without clarity of ownership and accountability for monitoring, managing and mitigating risks, patient safety could be compromised.

2. Reporting incidences of corridor care

There is currently no public reporting of incidents of corridor care. In their report HSSIB notes that varying definitions across organisations has complicated efforts to do this, stating:

“The absence of consistent reporting frameworks means that the impact of temporary care environments on patient safety may be poorly understood. This lack of visibility may contribute to inconsistencies in how data is interpreted and used, resulting in an incomplete picture of the risks and outcomes associated with these environments.”

Last winter the Department of Health and Social Care (DHSC) and NHS England said they would start to data on the number of patients who receive care corridor care. To date, there remains no confirmation nationally when this will begin. We urge DHSC and NHS England to deliver this commitment now. This data should be transparently published and released at regular intervals.

3. Capturing the patient safety consequences

As well as regular reporting of incidences of corridor care, we also need to better understand the impact on patient safety. We believe that the NHS needs to give further consideration as to how incidents of avoidable harm, where corridor care is a contributory factor, are captured. There should be a clear picture of the impact this is having and how organisations are mitigating risks to patients and staff.

HSSIB’s report notes that:

“… there were limited reported patient safety incidents where the temporary care environment itself was recorded as a factor.”

We think this is likely to be a reflection of existing reporting systems not capturing this accurately, or corridor care not being reported as a causal factor for other reasons, rather than it not being an influencing factor. In a blog last year, we outlined some of the challenges that the growing prevalence of corridor care poses to reporting and acting on patient safety concerns in the NHS.[6]

HSSIB also note that their investigation:

“…found that direct reports of patient safety concerns from patients was limited.”

Again, we would suggest that this is not necessarily evidence of an absence of concerns, but may be the result of patients:

• not being aware of patient safety risks around them in these circumstances.
• potentially being unwilling to raise these issues as formal patient safety concerns, or unaware of how best to approach this.
• being less able to report or recognise these issues due to types of conditions they may have, e.g. high acuity patients, patients with dementia etc.

4. Adaptations to mitigate risks

HSSIB’s report includes details of how hospitals are considering and mitigating the patient safety risks associated with corridor care. It includes specific examples of where there has been investment into physical changes to reflect the ongoing reality of corridor care. One such case highlighted is of an emergency department corridor where electric points and emergency call bells have been added. However, in some instances it also found:

“Concerns around normalising the use of temporary care environments can present a barrier to trusts putting all the possible patient safety mitigations in place when using temporary care environments.”

The desire not to normalise corridor care is fully understandable. However, it seems a perverse outcome that this in itself may be a barrier to making changes that lead to safer care, particularly when there is no choice but to use these environments. We think that there needs to be an honest debate about what good (or at least ‘less bad’) practice is, and for appropriate action always to be taken to reduce the risk of unsafe care.

Need for national action

Corridor care is a complex issue that is the result of a range of systemic problems faced by the health and care sector. While this report from HSSIB focuses primarily on local level changes, Patient Safety Learning believes there needs to be greater focus on what more can be done at a national level.

In December 2025, NHS England published new guidance setting out principles for providing corridor care in hospitals.[7] However, as reflected on in a blog by our Associate Director Claire Cox, there exists a significant gap between policy and practice.

“… this guidance is a near-perfect example of “work as imagined rather than work as done”. It is full of “shoulds”. Care should be to the same standard as on wards. Corridor care should only ever be used in absolute emergencies. Boards should have oversight. Staff should be supported. Patient safety should be paramount. Of course it should. No one working in the NHS disagrees with any of that. The problem is that what is being described simply does not reflect reality.”[8]

National action to tackle corridor care needs to go beyond issuing guidance. There is no quick fix to achieve this, it requires system leaders to get to grips with these issues and, supported by evidence and research, put in place plans to address them.

HSSIB’s report briefly references the regulatory role of the Care Quality Commission (CQC), noting the latter’s concerns about the use and normalisation of corridor care. We also think it would be helpful to have greater clarity around how the CQC is looking at corridor care in its inspection processes. Specifically, what actions it expects Trusts to take, when providing corridor care, to fulfil their Regulation 12 requirement to “prevent people from receiving unsafe care and treatment and prevent avoidable harm or risk of harm”.

Looking ahead, the 10 Year Health Plan states an intention to end corridor care as part of its shift towards a Neighbourhood Health Service.[9] If its ambition to ensure care happens as locally as it can is fulfilled in the long term, the pressure on hospital bed capacity that drives corridor care could reduce. However, significant detail of what this transition will involve, and at what pace it will be achieved, has yet to be made available.

In the meantime, we believe more could be done now to support individuals and organisations delivering corridor care.

Building on the local-level learning prompts in this report, we think there should be greater national support for sharing of good practice resources and case studies, so organisations can learn from each other. This could include both the specific steps organisations are taking steps to mitigate the patient safety risks, as well as how they are responding to and addressing staff concerns about working in these environments.

Share your experience

Do you have experience of corridor care either as a patient or a healthcare professional?

What impact have you seen on patient safety?

You can comment below (sign up here for free first) or email the editorial team at content@pslhub.org

References

1. HSSIB. Patient care in temporary care environments. 8 January 2026.
2. The Guardian. A&E in ‘big trouble’ because of ‘normalised’ corridor care, says leading UK medic. 30 December 2025.
3. Health Service Journal. ‘Corridor care’ approaches 1m cases a year. 4 December 2025.
4. Royal College of Nursing. On the frontline of the UK’s corridor care crisis, 16 January 2025.
5. APPG on Emergency Care. Corridor care. November 2025.
6. Clare Wade. The crisis of corridor care in the NHS: patient safety concerns and incident reporting. 6 February 2025.
7. NHS England. Principles for providing patient care in corridors. 11 December 2025.
8. Claire Cox. Corridor care guidance needs to move beyond what “should” happen and grapple honestly with why it isn’t. 18 December 2025.
9. Department of Health and Social Care. 10 Year Health Plan for England: fit for the future. 3 July 2025.

• All staff the investigation engaged with were motivated to make things as good as they could for patients. There was a strong desire not to have to use corridor care (one form of temporary care environment).
• There was inconsistent data and information gathering which meant the impact of temporary care environments on patient safety may be poorly understood.
• There were limited reported patient safety incidents where the temporary care environment itself was recorded as a factor.
• National and local data on the time patients are in a temporary care environments is variable and inconsistent.
• There is variation in the language used to describe temporary care environments at a provider level. This can cause inconsistency in how national policy is applied, this impacts the findings above.
• There was governance processes associated with the use of temporary care environments. These include evidence of risk assessments to identify areas that can be used as temporary care environments, and to identify patients who may be more suitable for care in these spaces.
• Temporary care environments were located across hospital estates, in emergency departments and in ward areas. They included beds and trolleys in corridors, upright and reclined seating areas, extra spaces being made on wards or in cubicles, and other converted spaces, for example side storage rooms, office spaces and family rooms.
• Trusts were making adaptations and adjustments to the environment, staffing and delivery of care where possible to mitigate patient safety risks when using temporary care environments.
• Staff described feelings of moral injury (negative emotions that arise because they cannot provide the level of care they would like) caused by having to care for patients in temporary care environments and the resulting compromise in patients’ experience.
• There are patient safety risks that are more challenging to manage when using temporary care environments including medical emergency situations, fire safety and infection prevention and control.
• There is varied understanding of what quality of care (including patient experience) is compared to patient safety at all levels of the healthcare system.
• Concerns around normalising the use of temporary care environments can present a barrier to trusts putting all the possible patient safety mitigations in place when using temporary care environments.
• Improving patient flow would reduce the need to use temporary care environments.
• There was evidence of increased awareness by most hospital staff of pressures across the health and social care system including primary care, ambulances and social care. There was a recognition of the need to work together to share and mitigate risks to patient safety.
• There are internal processes that hospitals can improve to support functions that assist timely discharge, including using multidisciplinary teams in complex discharge processes.

HSSIB makes the following safety observation:

NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and impact on patient safety.

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

Their latest report, Patient safety issues associated with electronic patient record (EPR) systems – a thematic review, summarises and analyses their previous investigation findings relating to EPR systems.[1] Its intention is to identify themes arising from these investigations and to share any additional safety learning.

Patient Safety Learning welcomes HSSIB undertaking this work. We contributed to this report during its consultation stage and, in this article, we set out our reflections on its findings.

EPR systems

An EPR is a set of electronic information about a single patient. It can include:

• a patients’ own notes
• test results
• observations by a range of different clinicians
• prescribed medications.

EPR systems are a way of managing clinical information with the intention of making it more easily accessible to both patients and healthcare professionals. They are becoming increasingly common in healthcare settings across the world and are a core part of how patient care is delivered. 

Patient Safety Learning perspective

When safely implemented, EPR systems can help to support and improve care and treatment. However, there are also significant patient safety risks associated with their implementation and use.

At Patient Safety Learning we highlighted a number of these issues last year in our report, Electronic patient record systems: Putting patient safety at the heart of implementation.[2] We believe patient safety should be core to all EPR systems, with robust safety considerations integrated throughout every stage of their introduction:

Development

Patient safety must be at the heart of the initial procurement, design, configuration and development of EPR systems. There should be a focus on:

• Interoperability (the ability to work with other computer systems or software used by the organisation to exchange and make use of information).
• Usability and design for safety, taking a user centred systems and human factors approach.
• Designing EPRs in collaboration with the staff who will use them.

Rollout

As EPRs are introduced into organisations, it is vital that the appropriate training and support is provided to staff. There needs to be:

• Sufficient usability testing (allowing staff who would be using these systems the opportunity to try them and provide feedback)
• Time allowed for amendments being made to reflect the most efficient and effective processes. Staff should not have to undertake significant workarounds to make an EPR functional; it needs to meet their needs as healthcare professionals and decision makers.
• A greater role for EPR manufacturers in providing training and support to staff.

Implementation

Once an EPR is in place, monitoring how it is operating in practice and learning and acting on any risk assessments, incidents or near misses that take place relating to this, is essential.

In each of these stages there should be clear steps to involve and engage both patients and frontline staff as part of this process.

HSSIB report

Considering the patient safety issues associated with EPR systems, HSSIB’s new report states:

“The review found that EPR systems could contribute to the risks of patient care being missed, delayed or incorrect. These risks were persistent despite national recommendations and actions seeking to mitigate them.”

They grouped their findings into three main categories:

1. Choosing an EPR system capable of meeting the needs of an organisation
2. Implementing an EPR system that meets the needs of users
3. Seeking feedback and ongoing EPR system optimisation

Choosing an EPR system capable of meeting the needs of an organisation

Before introducing a new EPR system into a healthcare organisation, it is vital that the appropriate planning and preparation takes place. Introducing these systems should be recognised as major organisational change programmes, and as such require the requisite investment of time and commitment from organisational leaders.

HSSIB’s report picks up on a number of issues in this area, highlighting that:

• Organisations do not always have a clear understanding of their requirements/needs from an EPR system, limiting their ability to match requirements to system capabilities.
• Choosing an EPR system at the procurement stage is complicated by this lack of understanding, which is often compounded by limited awareness of how these systems meet national requirements, including interoperability (the ability to work with other IT systems) and clinical risk-management standards.
• They found evidence of limited support at a national or regional level to help organisations identify their local requirements/needs for an EPR system.

Implementing an EPR system that meets the needs of users

At Patient Safety Learning we believe that healthcare professionals and those who will be the primary users of EPR systems should be involved in each stage of their design, planning and implementation.

HSSIB’s report also underlines the importance of this, noting issues including:

• Implementation of an EPR system was found to be a complex project that did not always effectively engage users to ensure it was safe and successful.
• When users were involved in EPR system implementation they were not always representative of those using the system in practice, with difficulties releasing staff from clinical work to contribute to implementation.
• Staff training in how to use an EPR system was often perceived to be limited. It did not always reflect how a system would be used in the ‘real world’, or offer advice on what to do if the EPR system failed.

Seeking feedback and ongoing EPR system optimisation

In our response as part of the consultation on this report, we emphasised the importance of the ongoing monitoring of how an EPR system operates after it has been introduced. 

This is a key issue we also highlighted in our report last year, connected with the often discussed concept in patient safety of the difference between ‘work as imagined’, ‘work as prescribed’ and ‘work as done’.[3] [4] With EPR systems, we need to look at the difference between how these are intended to work, and how they work in practice. Once an EPR system is live, there should be ‘continuous feedback loops’ to understand, and learn from, how it is working.

We are therefore pleased to see that HSSIB highlight a number of these issues in their report, including:

• Staff reported limited routes for raising concerns about poor functionality and usability of EPR systems, and limited action when concerns were reported that could impact on patient safety.
• Ongoing management of EPR systems, including upgrades and changes, did not always align with the digital standards for clinical risk management.
• EPR systems were not always kept up to date in line with national guidance and standards, or changes to internal care processes.
• There were limited opportunities for organisations to share their experiences of implementing and optimising EPR systems for the benefit of other organisations.

In seeking to assure the clinical safety of their health IT software, organisations in the NHS are required to meet a formal standard titled DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems. This standard, which is completed by a trust purchasing a system:

“… provides a set of requirements suitably structured to promote and ensure the effective application of clinical risk management by those health organisations that are responsible for the deployment, use, maintenance or decommissioning of Health IT Systems within the health and care environment.”[5]

DCB0160 documentation is typically completed by the clinical safety officer before the system is launched. The standard suggests that this also applies post launch. We think this exercise would be of particular value in the case of EPR systems, if it was also completed several months after launch as such a system may look and operate quite differently to the way it was expected to pre-launch.

At Patient Safety Learning, we believe that organisations should consider completing a DCB0160 post-implementation.

Concluding comments

This new report from HSSIB makes a strong and valuable contribution on the subject of EPR systems and patient safety. The local-level learning prompts in the report, intended to help organisations consider and mitigate risks around procuring, implementing and optimising EPR systems, are particularly helpful.

EPR systems have the potential to improve patient treatment and safety, increase efficiency and reduce the costs of healthcare. However, there are patient safety risks associated with their introduction and implementation. To fully realise their benefits, we need to ensure patient safety considerations are at the heart of their design, development and rollout.

References

1. HSSIB. Patient safety issues associated with electronic patient record (EPR) systems – a thematic review. 27 November 2025.
2. Patient Safety Learning. Electronic patient record systems: Putting patient safety at the heart of implementation. 31 July 2024.
3. Steven Shorrock. The Varieties of Human Work. 5 December 2016.
4. Claire Cox. Putting the writing on the wall: Explaining work as imagined vs work as done. 1 August 2023.
5. NHS England, DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems, Last Accessed 26 November 2025.

Choosing an EPR system capable of meeting the needs of an organisation

• Where EPR systems did not have the functions an organisation needed or did not support the user (patients and staff), they had contributed to patient safety incidents.
• There were inconsistencies in the terms used in the design of health IT systems and their functions, such as usability and functionality, and limited guidance to support understanding of these concepts in EPR system design.
• Organisations did not always have a clear understanding of their requirements/needs for an EPR system, limiting their ability to match requirements to system capabilities (the things a system can do).
• When procuring EPR systems, organisations sometimes faced challenges understanding system capabilities and whether they met required national standards, such as for interoperability (the ability to work with other IT systems) and clinical risk management.
• National and regional support for organisations to identify their local requirements/needs to inform EPR system procurement was limited.
• Some EPR system procurement decisions were perceived by staff to be influenced by factors other than system capabilities, such as cost savings.

Implementing an EPR system that meets the needs of users

• Variation in governance processes for implementing EPR systems at national, regional and organisation levels meant associated risks to patient safety were not always identified and mitigated.
• Implementation of an EPR system was found to be a complex project that did not always effectively engage users to ensure it was safe and successful.
• Local configuration of EPR systems had the potential to introduce new risks to patient safety, with investigations identifying where this had occurred without the organisation recognising and mitigating against these risks.
• Factors contributing to an organisation’s ability to locally configure EPR systems included the capacity and capability of digital teams, the level of involvement of users in testing, support from manufacturers, and awareness and application of digital standards for clinical risk management.
• When users were involved in EPR system implementation they were not always representative of those using the system in practice, with difficulties faced releasing staff from clinical work to contribute to implementation.
• Several organisations faced challenges relating to the availability of working hardware and Wi-Fi connectivity to support the use of EPR systems in different clinical environments.
• Staff training in how to use an EPR system was often perceived to be limited. It did not always reflect how a system would be used in the ‘real world’, nor what to do if the EPR system failed.

Seeking feedback and ongoing EPR system optimisation

• Staff reported limited routes for raising concerns about poor functionality and usability of EPR systems, and limited action when concerns were reported that could impact on patient safety.
• Ongoing management of EPR systems, including upgrades and changes, did not always align with the digital standards for clinical risk management.
• EPR systems were not always kept up to date in line with national guidance and standards, or to reflect changes to internal care processes.
• Factors contributing to limited ongoing optimisation of EPR systems after initial implementation included the need to manage a range of local digital priorities, limited collaboration between digital and clinical teams, cost of upgrades, and limited resourcing for ongoing work and infrastructure.
• There were limited opportunities for organisations to share their experiences of implementing and optimising EPR systems for the benefit of other organisations.

Safety recommendations

• HSSIB recommends that NHS Supply Chain reviews and amends the procurement framework for monitors/defibrillators to help ambulance services ensure they are fully considering the defibrillation/monitoring and cardiac diagnostic functions of the device when making purchasing decisions, to better reflect how these devices are used in practice.
• HSSIB recommends that NHS England/Department of Health and Social Care reviews and amends the service specification for primary percutaneous coronary intervention (PPCI) centres, to include a requirement for a function enabling two-way communication with ambulance crews for shared decision making about patients with a suspected STEMI. This is to ensure that patients are taken to the correct place of care and PPCI teams are responding to confirmed STEMI cases.

Safety observations

• Regulatory bodies can improve patient safety by supporting standardisation across manufacturers in how information from ECG traces is displayed.
• Manufacturers can improve patient safety by identifying the potential design barriers and enablers for ambulance crews entering information about a patient’s age or sex into a monitor/defibrillator. This could inform future device design to increase the likelihood that this information is entered when carrying out a 12-lead ECG using auto-interpretation.
• Algorithm developers can improve patient safety by collecting data from different ethnic groups across different geographical locations to help increase the global representation and accuracy of auto-interpretation algorithms for STEMI.
• Ambulance services can improve patient safety by informing regulators and manufacturers of instances where the use of monitor/defibrillators has impacted on patient safety.

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

From Autumn 2023, NHS organisations in England began to change the way they responded to and investigated patient safety incidents, moving to a new approach called PSIRF.[1] HSSIB’s latest investigation report looks at the implementation of PSIRF.[2]

PSIRF represents a significant shift in the way the NHS responds to patient safety incidents and is intended to be a major step towards establishing a systems approach to patient safety, maximising learning and improvement. A systems approach is one that focuses on understanding how different parts of the healthcare system interact, rather than placing blame on individuals when things go wrong.

PSIRF seeks to support a patient safety incident response system that integrates these four key aims:

1. Compassionate engagement and involvement of those affected by patient safety incidents.
2. Application of a range of system-based approaches to learning from patient safety incidents.
3. Considered and proportionate responses to patient safety incidents.
4. Supportive oversight focused on strengthening response system functioning and improvement.

Patient Safety Learning welcomes HSSIB undertaking this investigation. We contributed to this during its consultation stage and, in this article, we set out our reflections on its findings.

Applying PSIRF tools and guidance

The implementation of PSIRF is a complex innovation in the NHS’s approach to patient safety incident review and investigation. Its success depends, to a large part, on having the right organisational resources, commitment and support to deliver this.

HSSIB’s report says that the staff they interviewed for this investigation showed significant enthusiasm for employing the systems-based investigation approaches that PSIRF recommends. However, they note how those working in patient safety teams have also expressed concerns about the availability of training and support to implement these in practice. It states:

“Interviewees said that there was limited understanding and expertise among staff in applying system-based tools. Interviewees from HSSIB’s education team said most NHS staff attending courses had had no previous training, or any opportunity to practise applying the tools with a mentor with existing expertise to support them as they developed their skills. The comments received during interviews indicated that without these elements in place, it was unrealistic to expect NHS staff to use the tools. This means that the capacity for the tools to drive improvements is limited and their potential is only likely to be fully realised in organisations where the necessary support is in place”

We have heard similar reflections in the Patient Safety Management Network meeting. This is a peer network, open to everyone working in patient safety in the UK, which we host on our patient safety platform the hub.

The availability of training and support in the application of system-based tools recommended by PSIRF remains quite limited outside courses offered by organisations such as HSSIB. While there is some national support, such as specific webinars and events, much of the implementation of PSIRF is left to individual organisations.

There are other sources of external training support available, which can often provide an outline of the basics of PSIRF and its requirements. However, feedback we have received from our networks suggests this support is somewhat limited, not extending to detailed ‘how to’ resources for the implementation of Patient Safety Incident Investigations (PSIIs) or local learning responses.

At Patient Safety Learning, we have sought to provide support directly recently through a pilot Patient Safety Symposium. Organised with the Patient Safety Management Network and the Patient Safety Education Network, this event focused on the application of two specific PSIRF tools, the Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. 

Opportunities for improvement

HSSIB’s report sets out a number of suggestions to help further develop patient safety incident investigation under PSIRF. While these are broadly to be welcomed, below are several reflections that may be of value in identifying what further action is needed:

• HSSIB recommend a review and refresh of the NHS England Patient safety learning response toolkit. We agree that an update of this, with more multimedia resources aimed at making it more user friendly, would be welcome. However, if staff continue to lack access to appropriate training and support to use these tools, this update will ultimately only have a limited impact.
• We welcome the recommendation to publish more examples of PSIIs, not just for improving the process of investigations but to share the outcomes. This can help us to understand the causal and contributory factors of avoidable harm and the action needed to address it. This knowledge should not just be retained by the investigating organisation but should be disseminated for wider learning and action.
• We also reference the above issue in our response to Dr Penny Dash’s Review of the patient safety across health and care landscape in England.[3] In this, we highlight the lack of structured systematic approaches to learning and solution development as a significant gap in the current patient safety landscape in England.
• We agree in principle with the suggestion of providing access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance. However, if this ambition is to be realised, it is our view that this needs to be directed to a specific organisation. Our concern would be without this clarity and ownership; it is unlikely that this will be actioned.
• We welcome HSSIB promoting the potential role of networks for knowledge sharing and collaboration for investigation staff. This is something Patient Safety Learning actively contributes to through our charitable support of the Patient Safety Management Network and Patient Safety Education Network, hosted on the hub.

Engaging and involving patients, carers and families

As noted in the introduction, one of the four key aims of PSIRF is compassionate engagement and involvement of those affected by patient safety incidents. HSSIB’s report advises that while they have generally found this aim is welcomed by NHS staff, how this is done in practice is “variable and dependent on the organisational resources and support in place”.

The report highlights that significant differences can be observed in organisational approaches to this, citing patient safety incident investigations as a specific example. It notes that while in some Trusts these show clear evidence of patient and family involvement, in others this is largely absent or “in the background”.

It also points to inconsistency in capacity and resources. HSSIB state that while some Trusts have significant in-house expertise, such as investigators supported by dedicated family liaison staff, in other organisations the role of family engagement lead was simply an add-on to a person’s main job (often a clinical role).

Our conversations with members of the Patient Safety Management Network echo these findings. While there is support for greater patient and family involvement, there is also significant uncertainty and concern about how to approach and deliver this well. The network’s conversations also reflect another theme touched on by this report, that staff simply do not have the time available to effectively do this. The report states that as a consequence of time pressures, staff often rely on passive engagement methods, such as statements from those involved in incidents, rather than gathering information through interviews and discussions as recommended by PSIRF.

At Patient Safety Learning we believe this is an area that requires action. It seems clear that there is not adequate training or support to deliver patient, carer and family engagement as intended.

Organisational support and leadership

From their interviews in this investigation, HSSIB’s report states that staff:

“… were unanimous that organisational support and informed oversight were fundamental and essential to enable the shift to a system-based approach to investigation with compassionate involvement of those affected.”

However, their findings suggest there is considerable variation as to whether staff working with PSIRF saw this as being in place at their organisation. In some cases, they noted significant investment in setting up multidisciplinary teams and bringing in human factors and ergonomics expertise to the organisation. However, others suggested there had been little investment in their organisations, with staff finding they had limited time, training, experience or expertise in system-based investigation or how to meet PSIRF expectations.

The report also talks about the important influence that Boards and senior leaders have on the investigation approach and practice within an organisation. We would concur with this sentiment but would note that, in our experience, many Trusts find themselves not ready for systems thinking or do not understand what this means for them. Some Trusts are not financially able to reach the recommendations this may result in and therefore settle for a less optimum solution.

This inconsistency of approach can lead to significantly variability in how organisations learn and apply that learning to reduce avoidable harm. In turn, this will not address or could create inequity for patients.

Role of Integrated Care Boards

HSSIB also consider in their report the role Integrated Care Boards (ICBs) play in overseeing the implementation of PSIRF. The feedback they highlight paints a quite negative picture of this:

“Interviewees said there appeared to be a lack of oversight of PSIRF implementation, particularly in terms of knowing whether and how system-based investigation and engagement is being supported appropriately in organisations. Interviewees queried who was best placed to do the oversight needed and what exactly the expectation would be. NHS staff feedback, particularly from interviewees involved with Patient Safety Specialist training, was that external oversight from integrated care boards was 'patchy'.”

We would agree with this assessment. At Patient Safety Learning we have previously made the case in our report, The elephant in the room: Patient safety and Integrated Care Systems,[4]for the role that Integrated Care Systems and ICBs can play in improving patient safety.  However, there remain significant questions about how effective ICB oversight is of PSIRF and, particularly now, whether they even have the capacity to do this when they have been instructed to cut their running and programme costs by 50% by December 2025.[5]

The report also talks about the role envisaged for ICBs in coordinating cross-organisational incident investigations, as suggested by PSIRF guidance. It states that:

 “PSIRF guidance on oversight and patient safety incident response standards state that integrated care boards should provide the necessary support to coordinate these investigations. Interviewees said that NHS staff reported that in reality this support was often not offered or possible.”

As well as the capacity and funding constraints noted above, a report from HSSIB earlier this year highlighted the numerous challenges ICBs face in co-ordinating and supporting investigations in line with national expectations.[6]

You can read our response to this here.[7] We believe that ICBs need to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration.

HSSIB’s report suggests the following opportunity for improvement in this area:

“Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.”

While we understand the rationale for this suggestion, we think in practice it is hard currently to see an outcome from this that would rectify the problems highlighted above. HSSIB note in their report that NHS England has commissioned the Health Innovation Network South London to look at oversight by ICBs. At Patient Safety Learning we believe that without additional capacity and funding, it is hard to imagine what recommendations will flow from this that enable ICBs in practice to deliver effective oversight of PSIRF alongside support for cross-organisational investigations.

Concluding comments

For PSIRF to successfully meet its ambition of creating a fundamental shift towards learning and improvement in patient safety investigations, organisations need to implement this as part of a wider move towards a safe healthcare system. As emphasised in our recent response to the 10 Year Health Plan for England, we think this necessitates adopting a broader safety management system approach to healthcare.[8] This must be coupled with structured systematic approaches to learning about avoidable harm that leads to solution development and improvement action in the NHS.

As HSSIB’s latest report highlights, although PSIRF has now been rolled out across the NHS in England its implementation is far from complete. The findings of their investigation suggest there are significant variations in approach between Trusts, a theme also reflected in our report earlier this year looking in detail at Patient Safety Incident Response Plans.[9]

As noted in the report, this is also partly a reflection of the way in which PSIRF has been a national initiative but with heavy emphasis on local implementation:

“PSIRF was introduced without central financial support for organisations to implement it. Interviewees said the consequences of this are reflected in the differing priority and allocation of resources for PSIRF. They emphasised the imperative for dedicated resource for investigation and engagement work and said that without central funding to enable organisations to meet the expectations set in the PSIRF patient safety incident response standards variation was inevitable, particularly given the financial pressures and competing priorities organisations faced.”

Although this investigation has focused on how patient safety responses and investigations take place under PSIRF, the bigger question is how this variation in approaches between Trusts has impacted on patient safety, which currently remains unquantified and unanswered. Ultimately this initiative must be judged on its implementation and effectiveness in reducing avoidable harm.

References

1. NHS England. Patient Safety Incident Response Framework. Last accessed 6 October 2025.
2. HSSIB. Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development. 10 October 2025.
3. Patient Safety Learning. Review of patient safety across the health and care landscape: Patient Safety Learning’s response, 16 July 2025.
4. Patient Safety Learning. The elephant in the room: Patient safety and Integrated Care Systems, 11 July 2023.
5. Health Service Journal. ICBs ordered to cut costs by 50%. 12 March 2025.
6. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025.
7. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning's response to HSSIB investigation, 13 February 2025.
8. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s response, 14 August 2025.
9. Patient Safety Learning. What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? 7 May 2025.

Applying investigation tools, templates and guidance

• The shift to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by staff.
• Using system-based tools is a skilled activity. Expertise builds over time with practice, support and guidance from those with existing expertise and experience.
• Currently there is a gap between staff’s awareness that there are tools and guides in the PSIRF toolkit and having the necessary support and expertise to be able to use them in practice.
• Training for staff has provided limited opportunities for them to practically apply and discuss using the tools and guides in the toolkit.
• The current design of some PSIRF tools and guides may limit staff’s ability to use them in practice.
• Feedback indicates staff find it particularly challenging to apply the tools and guides in investigations about mental health care.

Engaging and involving those affected by patient safety incidents

• The principle of greater engagement and involvement in investigations is welcomed by staff and seen as the right thing to do.
• Progress towards greater engagement is variable depending on the organisational support available to enable this work.
• Time pressure was the main reason given for continuing to rely on statements from those involved in incidents rather than gathering
• information through interviews and discussions as recommended by PSIRF.
• Conversations which involve apologising to a patient, family or carer for harm caused during their care require specific knowledge, skills and attributes as detailed in the PSIRF patient safety investigation standards.
• Specific challenges in engaging with patients, families and carers were highlighted in investigations in mental health organisations.

Organisational support for patient safety incident investigation

• Organisational support and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected.
• Boards and senior leaders have a powerful influence on the approach and practice of investigations.
• Some organisations have invested in implementing PSIRF and have provided the organisational support needed, for example by establishing safety teams with dedicated investigators and engagement leads, which also provide a space for sharing and learning.
• Some organisations have not invested in implementing PSIRF and progress has been limited by the lack of dedicated roles and resource. For example, some staff have attended PSIRF training in their own time as their organisation has not provided protected learning time.

External influences on investigation practice

• The lack of central funding for PSIRF implementation may have contributed to the variation in support provided within organisations to implement it.
• Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.
• Investigations involving multiple providers are difficult for a single organisation to co-ordinate.
• Integrated care boards have not always been able to provide the support and co-ordination needed for cross-provider investigations as expected under PSIRF. This means investigations often focus on one element of a patient’s journey, missing valuable learning and meaningful improvement opportunities.
• Coroners’ expectations can influence an organisation’s choice of learning response to an incident.

Other PSIRF learning responses

• Staff value having the flexibility to choose a range of learning responses to patient safety incidents.
• After action review is the chosen learning response to many incidents that previously would have triggered an investigation. It is important that facilitators are appropriately trained and that the governance processes for this learning response are robust.
• There is interest in and an aspiration to use thematic analysis but there are challenges with applying this method which mirror those of applying system-based tools.

Themes arising from stakeholder interviews identified in this report including:

• Some improved outcomes - some progress has been made in maternity and neonatal outcomes, staffing levels and governance arrangements.
• Complex national infrastructure - national maternity and neonatal systems are overly complex.
• Collaboration and information sharing between national organisations - national collaboration efforts are inconsistent and variable.
• Development, oversight and implementation of recommendations - too many recommendations exist, with limited implementation.
• Local governance arrangements - local governance of maternity services often operates in isolation from the wider organisation
• Risk awareness - services still lack the consistent ability to identify and respond to clinical risks.
• Potential for learning in maternity and neonatal services - there is limited potential to learn from harms that happen to women and babies during pregnancy, labour and birth.
• Compounding patient harm - patients experience compounded harm due to issues within the wider healthcare system, particularly the way local investigations are carried out or the way complaints/concerns are managed.
• Compounding staff harm - staff are also affected by cumulative stress and harm.
• Inequalities - disparities in care and outcomes persist because of health inequalities.
• Training and standards - there are concerns about the standards set in undergraduate and postgraduate education and whether these can be adhered to in practice.

On day 1, the patient was admitted to an acute hospital following a fall at home. During his time in hospital, a change was made to his diabetes medication regimen from metformin (one form of medication used to treat diabetes) to insulin (a hormone that helps the body to use glucose for energy). On day 4, education was provided to the patient in hospital to support him to administer his own insulin (self-administer) after discharge. On day 7, the patient was discharged home. District nursing support was arranged for wound and catheter (a tube used to drain urine from the bladder) care.

On day 13, 6 days after discharge, the patient had a follow-up call with the hospital diabetes team. The patient told the diabetes team he was unable to remember all of the information about his insulin medication and he had not been self-administering. The diabetes team referred the patient via his GP for district nursing support to help with this. The district nursing team continued visits to the patient for wound care but were unaware a referral from the GP for insulin support was awaited.

On day 22, 17 days after the patient was discharged, the district nursing team visited the patient out of hours for a catheter issue. During this visit, the patient disclosed he had not taken any insulin since leaving hospital. The patient’s blood glucose reading was high and a decision was made to re-admit him to hospital because of this. He was taken to the hospital by ambulance, stayed overnight for observation and was discharged the following day.

Findings

• On the patient’s admission, conflicting information in his patient records created challenges for staff in understanding whether he was taking any medication to manage his diabetes.
• The patient’s individual circumstances were considered by the hospital diabetes specialist nursing team when arranging education for self-administering his insulin. However, there was no documentation available to establish whether the patient was able to effectively self-administer his insulin after the education and manage his diabetes during the rest of his inpatient stay.
• The patient’s need for district nursing support for insulin administration was understood and documented differently by different hospital teams, and between hospital and district nursing teams. The patient received support for wound care only and did not receive support in administering insulin after being discharged.
• The processes for managing medications on the ward and in the hospital’s discharge lounge did not identify that the patient was discharged home with two different insulin pens, including one he did not need. This resulted in confusion for the patient about which one he should use.
• Post-discharge, follow-up processes from the hospital diabetes specialist nursing team identified that the patient was not taking his insulin; this provided an opportunity for further support to be arranged.
• Unlike hospital ward staff, the hospital diabetes nurse specialist service could not refer the patient directly to the district nursing service to arrange support. Instead, they had to contact the GP for a referral to be made. This delayed the patient receiving insulin support in the community.
• A mismatch between demand and capacity within the district nursing service often led to visits being overscheduled and time restrictions during patient visits. This limited the wider interaction staff could have with patients outside of the specific focus of their visit.
• District nursing services identified that the patient was not taking his insulin by chance during a routine wound care visit before any additional referral for insulin support, to district nursing services could be made by the GP practice.
• Due to commissioning arrangements, there was an inequity in the availability of post-discharge specialist diabetes nursing support in the community that could be offered to the patients in the region, resulting in this patient not being able to access a specialist community diabetes service.
• Multiple healthcare providers were involved with the patient’s care. They used different electronic patient record (EPR) systems that did not interact to share information about the patient’s care and referral status.

Local-level learning prompts

The following prompts are provided by HSSIB to help organisations improve the safety of patients who need insulin and are being discharged from an acute hospital to the community.

Care in hospital

• How does your organisation support staff to quickly and easily identify what medication a patient is currently taking and their medication history?
• How does your organisation make sure that patients have access to specialist diabetes support including out of hours?
• How does your organisation support staff to gain an understanding of the care patients with diabetes need?
• How does your organisation ensure that education given to patients emphasises the importance of taking insulin and is appropriate and tailored to their individual needs?
• How does your organisation support patients to feel confident and safe in self-administration of insulin?
• How does your organisation support patients to understand how to raise concerns about self-administration of insulin?
• How does your organisation consider family, carer or living arrangements when providing education on self-administration?
• How does your organisation support staff to ensure that medications for an individual patient that are no longer needed are disposed of safely?

Planning for discharge in hospital

• How does your organisation support staff to complete medication checks before patients are discharged home with medications?
• How does your organisation follow up with patients post discharge, whose insulin regimen has started or been changed while in hospital?
• How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?
• How does your organisation support staff to identify and be able to refer to local diabetes specialist services when patients are discharged home?
• Does your organisation support staff to make timely and effective referrals to district nursing services to support insulin administration?

Care in the community

• How does your organisation enable staff to understand that a patient referral has been received, actioned, and completed?
• How does your organisation ensure enough time is allocated to district nursing visits based on individual patient needs?
• How does your organisation support staff to take rest breaks and reduce the risk of staff fatigue?

• Prison operational IT systems (the Prison National Offender Management Information System and the Digital Prison Service) and the prison healthcare IT system (SystmOne) are not able to automatically share information between each other.
• Important patient information, such as risks they pose to themselves or others, is not readily available to healthcare staff when seeing patients.
• Prison healthcare department admin staff have to duplicate medical appointments onto both the healthcare and the prison IT systems. This can amount to thousands of appointments per month, expending time and resource, while also creating multiple opportunities for user input error.
• The prison healthcare IT system has been adapted in readiness to receive and exchange information with the prison IT systems. The prison IT systems have not been adapted and there is currently no plan to adapt them.
• Patients who are detained on remand for short periods of time may have their continuity of care in the community negatively impacted by being GMS registered with the prison GP, and therefore de-registered from their community GP.
• Patients are given information about GMS registration during the prison reception process, when they are asked to consent to the sharing of their medical records. There is limited time for patients to consider the information or ask any questions and understand what they are consenting to, during what HM Prison and Probation Service describes as a ‘stressful experience’.
• There is variability across prisons in the understanding prison healthcare staff have about the GMS consent and registration process, resulting in different processes. This causes difficulties in maintaining continuity of care for some patients.
• Prisons housing remand prisoners experienced much lower GMS registration rates due to remand patients expressing concern about the impact on them of registration if they are released from remand.
• Each prison healthcare department is viewed by the NHS as an independent GP practice; however, for the purposes of GMS registration, all prison healthcare departments are viewed as surgeries under a single prison GP practice. This has led to confusion at all levels in healthcare, from national leaders to provider staff, about the consent process for the transfer of medical records.
• Some patients are being asked to re-consent to GMS registration when they move to a new prison. This is creating inconsistencies in the way consent is sought and gaps in patients’ medical records, making continuity of care difficult as patients move between prisons and to the community.
• Patients who do not consent to GMS registration do not automatically appear on national screening programmes, such as the breast screening and bowel screening programmes.

HSSIB makes the following safety recommendations

Safety recommendation R/2025/067:

• HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means for them. This is to ensure patients are making informed decisions about their healthcare provision, therefore improving patient safety.

Safety recommendation R/2025/068:

• HSSIB recommends that NHS England/Department of Health and Social Care, working with healthcare service providers and their healthcare teams at prisons which hold remand prisoners, reviews and amends the process for GMS registration of patients on remand. This is to ensure a consistent approach to GMS registration across the prison estate, which acknowledges the potential negative impact short-term changes in care provision may have on the continuity of care for patients who have been remanded in custody.

Safety recommendation R/2025/069:

• HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of need.

Safety recommendation R/2025/070:

• HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of need.

Local-level learning

HSSIB has identified local-level learning for prison healthcare providers and teams, who can improve patient safety by:

• aligning local policies, in relation to consent for GMS registration, with NHS England guidance on informed consent principles
• assisting staff to adapt their approach to consent discussions with patients in recognition of the stressful reception environment.

HSSIB has identified local-level learning for prison healthcare providers and teams, who can improve patient safety by adopting processes to avoid patients who are GMS registered within the prison system being automatically asked to re-consent when transferring to a different prison.

HSSIB has identified local-level learning for prison healthcare providers and teams, who can improve patient safety by supporting patients to pre-register with community GPs as part of release planning.

HSSIB has identified local-level learning for prisons who can improve patient safety by adopting a mechanism for healthcare providers and teams to highlight patients who may not be medically suitable for release on temporary licence (ROTL) and, where appropriate, being involved in the decision process.

Between 1 April 2024 and 31 March 2025

• 19 investigation reports published.
• HSSIB made 310 safety recommendations to 61 organisations to influence improvement.
• 14,427 new students registered across all HSSIB education courses
• An example of our patient and family engagement - HSSIB spoke to over 100 patients and families during out mental health inpatient investigations.