We were among the small number of trusts in England that were part of the pilot programme for the Patient Safety Incident Response Framework (PSIRF). This is now required for all providers as part of the NHS contract.
It is a national initiative which is designed to further improve the quality and safety of the care we provide through learning from patient safety incidents.
The PSIRF outlines how providers should respond to patient safety incidents, and how and when an investigation should be carried out. It includes the requirement for the publication of a local Patient Safety Incident Response Plan (PSIRP), which sets out how we will continually improve the quality and safety of the care we provide, as well as the experience which patients, families and carers have when using our services.
On this page
Investigations
The Trust has a range of learning response methods which we use to learn from patient safety incidents. The method selected is the one which will be most effective to help us identify how an incident occurred, and what improvements we can make.
During a learning response or investigation, we will provide each patient, family member or carer with a named contact who will listen to their questions or concerns before making sure that they are answered openly and honestly.
The learning identified and improvements planned will be shared with those involved. This may be during a conversation, in a written report, or in a letter.
We will encourage and support all those involved to participate throughout this process and are keen to ensure that everyone’s voice is heard.
Local priorities to investigate
The Trust has developed a local patient safety risk-based plan.
This has been profiled using organisational data from recent patient safety incident reports, complaints, patient advice and liaison service, inquests, mortality reviews, clinical reviews and divisional engagement.
This review takes place each year and currently, we have identified the following events we must investigate through a patient safety incident investigation (PSII) in addition to the national ‘must dos’:
- Barriers to effective discharge due to issues in consideration of system elements (for example, where transport may not have been appropriate for the patient’s needs).
- Problems with the clinical care/management of diabetic patients when diabetes is not the primary reason for admission to a service or the hospital.
- Patient on an end-of-life pathway receiving unnecessary/inappropriate clinical interventions.
- Barriers to effective inclusivity (for example, effective pain assessment and relief for patients with dementia).
- Incidents with a potential for adverse impact on staff wellbeing where fundamentals of care cannot be provided due to staffing challenges.
Resource for a small number of additional PSIIs has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.
National priorities to investigate
The national framework defines a number of national priorities which we must investigate locally through an in-depth investigation, called a patient safety incident investigation (PSII).
This uses a human factors, complex systems approach, informed by improvement science to prevent or continuously and measurably reduce repeat patient safety risks and incidents. These are:
- Those which meet the criteria set in the never events list
- Those which meet learning from deaths criteria
External reviews
There are a number of nationally-defined priorities which require onward referral for investigation or review by another team which (in 2024/25) are:
- Incidents which meet the ‘Each Baby Counts’ and maternal deaths criteria – Maternity and Newborn Safety Investigation programme (MNSI)
- All perinatal and maternal deaths – MBRRACE (Mothers and Babies: Reducing risk through Audits and Confidential Enquiries)
- Mental health-related homicides by persons in receipt of mental health services or within six months of their discharge - relevant NHS England and NHS Improvement regional independent investigation team
- Child deaths - child death panels
- Deaths of persons with learning disabilities - LeDeR (Learning Disabilities Mortality Review programme)
- Incidents in screening programmes - Public Health England’s regional Screening Quality Assurance Service and commissioners of the service
- Deaths of patients in custody, in prison or on probation where healthcare is/was NHS funded and delivered through an NHS contract - Prison and Probation Ombudsman.