Reflections on PSIRF

The deadline to transition to the Patient Safety Incident Response Framework (PSIRF) - Autumn 2023 - has now passed. The transition to PSIRF, replacing the previous Serious Incident Framework, has resulted in a considerable shift to the way in which the NHS responds to incidents relating to patient safety. There is now a focus on examining patient safety incidents ‘in the spirit of reflection and learning’, rather than as part of a ‘framework of accountability’. 

This insight explores some of the key issues that have surfaced since implementation and how these issues can be approached.

Increasing engagement and involvement with those affected by patient safety incidents 

Compassionate engagement is one of the key objectives of PSIRF. ‘Those affected’ should be taken to include staff and families in the broadest sense. NHS England has set out its expectations on engagement in its ‘Guide to engaging and involving patients, families and staff following a patient safety incident’. The guidance considers there to be four steps of engagement; before contact, initial contact, continued contact and closing contact. Throughout these stages, there must be meaningful involvement from families in the investigation, from defining terms of reference, to agreeing timeframes for completion.

Organisations must work harder than before to actively involve families in investigations. It is expected that organisations will struggle with resourcing and capacity, as there is increased work involved with engaging with families. Many organisations differentiate the roles of Family Liaison Officer, the point of contact for bereaved families, from those who undertake investigations. It is easy to see how this gap could stifle communication. 

Organisations must adapt to new ways of working. Some  are implementing additional technology, in the form of ‘incident trackers’, allowing all staff involved in patient safety investigations to monitor engagement with families throughout the process. This ensures families are kept at the forefront of investigations and permits involvement from all key stakeholders in an investigation to be involved in the conversations. 

Flexibility of approach 

PSIRF also focuses on considered and proportionate rationale when responding to patient safety incidents. This acknowledges the limited resources available, moving away from the need to investigate every incident that previously met a subjectively defined ‘level-of-harm’ threshold. PSIRF requires local decision making and responsibility with regards to learning, by identifying whether the risks posed are already being explored. This means that some patient safety incidents, which would have previously warranted investigation, may not require full patient safety incident investigations (PSII’s) under the new framework. Alternatives to PSII’s include swarm huddles, MDT reviews, after-action reviews, thematic reviews and horizon scans.

Whilst this flexibility is welcomed, there are inevitably concerns surrounding achieving consistency in approach. As there are no obvious right answers, this aspect of PSIRF is likely to require some getting used to. Organisations must ensure decision making is justified in line with similar incidents. 

Understandably, compassionate explanations must still be given to families where full investigation has not been deemed necessary in the circumstances, to ensure their concerns are heard. Failures in this regard could result in litigation, that was perhaps avoidable, if families feel they have not had answers.

PSIRF and the coronial process

Another fundamental pillar of PSIRF is the systematic approach to learning. This has resulted in the move away from ‘root cause analysis’ (RCA) investigations, instead focusing on common system learning themes, as opposed to cause and effect. There is no longer an expectation to make judgments about the cause of death within PSII’s. There are concerns that organisations will not be offering the same patient specific assurance for the coroner (evidence that learning from the cause of the incident has taken place) with PSII’s, as the RCA once did. 

Whilst PSIRF requires changes in approach to patient safety incidents, there is no change to the inquest process.  If a death is being reviewed by the coroner, the coroner will be entitled to receive the investigation report, as before. Similarly, if a different learning response has been carried out, any output must also be shared with the coroner.  

As investigations will now take a more holistic approach, it is important that those giving evidence on a PSII report are well-prepared for the inquest hearing. Witnesses must focus on the patient at the heart of the incident to avoid losing sight of the individualistic approach that inquests take, for the benefit of both the family and the coroner.

On the other hand, if the flexibility granted under PSIRF has meant an investigation was not warranted, it is important that explanation and the reasoning for such is given to the coroner. With this may come a greater risk of Prevention of Future Deaths reports (PFDs) if the coroner does not feel any learning assurance is strong enough. Although only time will tell in this regard, given PSIRF is still in its early stages, organisations must be wary of this risk.

Though change is not without its challenges, we are hopeful that PSIRF will make a positive difference to patient safety. 

If you need any assistance following the transition to PSIRF, including support with your patient safety incident investigation reports, please do not hesitate to get in contact with our team of experienced healthcare lawyers.