Part 4: The Health Services Safety Investigations Body Reports Section 113: Final reports
Section 113(1) outlines that the HSSIB must publish a "final report" on the outcome of its investigations. The report must include a statement of findings of fact and an analysis of the investigation’s findings together with any recommendations as to the action to be taken by any person that the HSSIB considers is appropriate. If the investigation relates to an incident that did not occur during the provision of NHS services, the report must also set out the HSSIB’s conclusions on the matters it considered with regard to section 110(3). This section outlines that in these circumstances the HSSIB must consider whether, in relation to any risks identified, the systems and practices in the provision of NHS services could be improved.
	In making recommendations, the HSSIB must focus on addressing risks to the safety of patients, rather than on the activities of individuals involved in the incident. In particular, the final report may not include any assessment or determination of blame, civil or criminal liability, or whether action needs to be taken in respect of an individual by a regulatory body (under section 110(4)).
	Set out by section 113(5), protected material may be disclosed in the final report if the HSSIB determines that the benefits to patient safety served by the disclosure outweigh any adverse impact on current or future investigations by deterring people from providing information to the HSSIB, and any adverse impact on securing the improvement of the safety of health care services provided to patients in England.
	Names of individuals who provided information to the HSSIB for the purposes of the investigation, or who were involved in the incident under investigation, must not be included in the report, unless they have given their express permission to the HSSIB to do so.
	Where an investigation is carried out following a direction from the Secretary of State under section 111, the HSSIB must send a copy of the final report to the Secretary of State.