HSSIB Investigation Report: Patient care in temporary care environments (8 January 2026)

Summary

This report is intended for healthcare organisations, policymakers and the public to help reduce patient safety risks in relation to temporary care environments. It summarises the analysis and findings of the Health Services Safety Investigations Body's (HSSIB’s) investigation, and provides a safety observation and learning prompts for organisations to consider when managing temporary care environments.

You can read Patient Safety Learning's response to this report here.

Content

Key findings in this report include:

• 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.