On the 18 June 2026, the Health Services Safety Investigations Body (HSSIB) published a new report summarising a rapid investigation focused on patient safety issues within a regional care system. It looked specifically at a case where multiple organisations were involved in providing care across a care pathway. In this blog, our Associate Director Claire Cox sets out reflections on the report’s findings.
The most recent HSSIB learning report on patient safety across regional care pathways offers an important, if uncomfortable, insight into the realities of delivering care across organisational boundaries. While framed as learning, the findings expose fundamental gaps in oversight, clarity and system leadership, which pose significant risks to patient safety.
A care pathway is a structured, evidence-based framework that describes the sequence of care and interventions a patient should receive for a particular condition, population group or healthcare need. It sets out how different services and professionals work together to deliver coordinated, high-quality care across the patient's journey.
The HSSIB investigation examined a redesigned regional pathway involving multiple organisations and a centralised specialist service. However, the report deliberately omits specific details of the pathway, organisations and patient group involved.
While this is understandable from a confidentiality perspective, it creates a key limitation: without a clear understanding of the full patient journey, it becomes much harder to articulate where risks emerge, accumulate and, ultimately, result in harm.
The invisible patient journey
One of the most striking issues raised by the report is the system’s inability to fully understand or monitor patient harm across the pathway. This is perhaps unsurprising. Care pathways that span multiple organisations are non-linear, dynamic systems, where risks rarely arise at a single point. Instead, harm often reflects latent system failures, decisions, constraints or assumptions made early in the pathway that only manifest much later.
The investigation highlights several critical system weaknesses:
- Differences between how the pathway was designed and how it actually operated.
- A lack of shared understanding between organisations about what the pathway could realistically deliver.
- Limitations in the technology and digital systems used to support the pathway.
- Limited data sharing and inconsistent performance insight across providers.
These issues are particularly evident in the technology underpinning the pathway, where a lack of interoperability between organisational digital systems means critical patient information is not consistently shared or visible across services. In practice, this results in manual workarounds, duplication and reliance on incomplete data. The safety implications are significant: clinicians are often making decisions without a full understanding of a patient’s history, delays occur in accessing or transferring information and opportunities for proactive intervention are reduced.
Collectively, this creates a scenario where no single organisation holds a complete picture of the patient journey, meaning emerging harm cannot be reliably identified.
From a patient perspective, it is reasonable to expect far greater visibility of the pathway they are moving through—not just who is providing their care, but how that care is organised end-to-end. This includes clarity on what the pathway looks like, the key decision points that may affect their treatment, and how and when care may escalate if their condition changes.
They might also reasonably expect to know how risks to their safety are being identified, shared and actively managed across organisations. Without this transparency, patients are effectively navigating a system that is opaque, fragmented and difficult to understand.
In such circumstances, meaningful collaboration becomes extremely challenging. Shared decision making depends on a shared understanding of both the clinical situation and the system through which care is delivered. Similarly, where risks are not visible to patients, there can be no clear line of accountability for how those risks are mitigated.
If care pathways are to function safely across organisational boundaries, they must be understandable not only to professionals within the system but also to the patients who rely on them.
The accountability gap
A consistent theme throughout the HSSIB report is the absence of sustained oversight.
Although a cross-organisational implementation board initially existed, oversight from the Integrated Care Board (ICB) reduced before the pathway was fully embedded.
The consequences were predictable:
- No shared governance framework post-implementation.
- No agreed evaluation plan.
- Limited escalation of risks.
- Disconnected data and performance monitoring.
This reflects a classic system failure: accountability without ownership.
If no organisation or system leader maintains end-to-end ownership of a pathway, then:
- Risks fall between organisational boundaries.
- Mitigations are inconsistent or absent.
- Learning is localised rather than system wide.
As highlighted by another HSSIB report last year, there is a lack of clarity about how patient safety is managed between ICBs other healthcare providers, including lines of safety accountability. This leads directly to gaps in oversight of cross-organisational safety risks.
Implementation versus reality: the risk of 'work as imagined'
Another critical safety issue is the mismatch between the pathway as designed ('work as imagined') and its real-world operation ('work as done').
The report highlights:
- A business case that was not fully realised.
- Resource assumptions (e.g. bed capacity) that did not materialise.
- Divergent expectations among organisations about pathway capability.
This is not a minor operational issue, it is a core patient safety risk.
When services are designed based on assumptions that are not delivered in practice:
- Demand exceeds capacity.
- Access thresholds shift informally.
- ·Staff are forced into workarounds.
- Clinical decision-making becomes inconsistent.
Over time, this creates unstandardised care and inequity of access, both of which were flagged as concerns in the investigation.
Culture, communication and friction
The report also surfaces issues that are often underplayed in pathway redesign, relationships and behaviours between teams.
Findings include:
- Differences in risk perception between organisations.
- Disagreements affecting clinical decisions.
- Examples of incivility.
- Barriers to shared learning.
- Lack of interoperability between organisation digital systems.
These are not 'soft issues', they are direct contributors to patient harm. Where communication breaks down:
- Information is lost or misinterpreted.
- Decisions are delayed.
- Trust erodes across organisational boundaries.
In cross-system pathways, psychological safety and collaboration are as critical as infrastructure and process design.
What could strengthen learning?
While the report provides valuable system-level insights, there is an opportunity to go further in translating findings into practical improvement. Two approaches could add depth:
1. After Action Review (AAR) at system level
A structured, multi-agency AAR could:
- Reconstruct the pathway end-to-end.
- Identify where assumptions diverged from reality.
- Surface latent conditions contributing to risk.
- Build shared understanding across organisations.
This would move learning from 'what happened' to 'why it made sense at the time'.
2. Transformative (tabletop) simulation
Given the complexity of regional pathways, simulation offers a powerful way to:
- Test proposed improvements in a safe environment.
- Explore system stress points (capacity, transfers, escalation).
- Identify unintended consequences before implementation.
In effect, simulation allows systems to experience the pathway as patients do across boundaries, not within silos.
The role of integrated care boards: a system risk?
Perhaps the most significant implication of this report is what it reveals about the current maturity of system oversight.
ICBs are expected to:
- Commission across pathways.
- Ensure safety across organisational boundaries.
- Use data to drive improvement.
However, the report evidences:
- Limited access to consistent safety data.
- Reduced capacity following structural changes.
- Difficulty maintaining ongoing oversight of complex pathways.
Again this is not an new issue and is a theme that we have seen in previous HSSIB investigations, including a report last year looking at the implementation of the Patient Safety Incident Response Framework.
This raises a critical question: do current system structures have the capability and capacity to oversee patient safety at pathway level?
If the answer is uncertain, then this is itself is patient safety risk, one that is largely invisible to the public.
How might the emerging quality strategy address this?
The forthcoming NHS Quality Strategy presents a critical opportunity to address many of the systemic issues highlighted in this report, particularly the fragmentation of safety across organisational boundaries. The 10 Year Health Plan stated that alongside the National Quality Board its aim would be to address a crowded and unclear quality landscape and provide a single and authoritative determination of quality. This aligns directly with the need identified here: clearer expectations, better measurement and more coherent oversight across systems.
However, emerging national discussion suggests there are still important gaps to resolve, including concerns about whether patient safety will be given sufficient prominence, and whether expectations for providers and system leaders will be clear enough to drive meaningful change.
If the Strategy is to respond effectively to the risks identified in this HSSIB investigation, it must move beyond treating safety as one dimension of quality and instead position it as a central organising principle of system design.
This creates a significant opportunity to design cross-system safety into:
- service planning
- service delivery
- accountability frameworks
- performance management
- data capture and intelligence.
Without this, there is a real risk that existing fragmentation is reinforced: where metrics are numerous but unaligned, accountability remains diffuse, and no single entity holds responsibility for understanding risk across the whole patient journey.
Conversely, a coherent and safety-led strategy could provide the support needed for ICBs and providers to jointly own pathway outcomes, supported by shared data, stronger governance and clearer system leadership. The absence of prescriptive targets may offer flexibility but it also increases the importance of how strongly patient safety is prioritised and operationalised in practice.
Final reflection
This HSSIB report highlights a fundamental truth: patient safety does not solely reside within organisations; it resides within pathways.
The 10 Year Health Plan for England envisions a significant shift in the coming years towards more neighbourhood and system-based models. As this transition takes place, the risks identified in this report will only become more pronounced.
Without clear end-to-end ownership, shared data and intelligence, robust evaluation, and strong cross-system leadership, we risk designing pathways that look coherent on paper but are fragile in practice, and where safety is too often an afterthought. The forthcoming NHS Quality Strategy could potentially present a opportunity to tackle these issues, designing for safety, to ensure safe outcomes, processes and behaviours.
The challenge now is not simply to learn from this report but to recognise that these issues are unlikely to be isolated. They are systemic and they demand a system-level response.
