Key takeaways
Clarification of the interaction between PSIRF and the coronial process
Evidence gathered for the 2 processes must remain distinct.
Coroners should not expect an RCA style investigation
Coroners may need to obtain causation evidence from other sources.
Clear communication helps manage family expectations
Sensitively and clearly explaining the distinction between PSIRF’s focus on learning and the purpose of the coronial process manages expectation and helps to avoid confusion.
NHS England recently met with the Chief Coroner to address a growing area of tension: how the Patient Safety Incident Response Framework (PSIRF) interacts with coronial investigations.
The latest communication from NHS England emphasises that coroners should no longer expect healthcare providers to produce Root Cause Analysis (RCA) style reports under the PSIRF process. These previously focussed on establishing the 'root cause' of an incident, and in turn often assisted coroners directly in determining whether an act or omission contributed to a person’s death.
The core challenge: different systems, different purposes
PSIRF and the coronial process serve fundamentally different purposes. PSIRF decisively moves away from the causation focused RCA model used under the former Serious Incident Framework. Instead, PSIRF prioritises organisational learning, avoids apportioning blame and explicitly excludes establishing cause of death.
Coroners, however, operate under a legal duty to answer four statutory questions - including how the deceased came by their death. This often requires the coroner to determine clear findings on causation, something PSIRF deliberately does not provide.
This shift has understandably led to tension. Many coroners have long relied on RCA style reports that set out detailed chronologies and causal findings. PSIRF learning responses do not fulfil that function.
What have the Chief Coroner and NHSE agreed?
The recent communication from NHS England sets out several important clarifications:
Coroners should not expect an RCA style investigation.
Evidence gathering for PSIRF and for inquests must remain distinct.
Coroners may need to obtain causation evidence from other sources.
Investigations under PSIRF (such as Patient Safety Incident Reviews) can still be useful in inquests; but only as supplementary material. Such reports may help coroners understand system-wide issues or improvement actions, with the caveat that they are not suitable as primary evidence for determining how a death occurred.
Practical considerations for healthcare providers
Preparing for inquests
Healthcare provides should work proactively with coroners to identify what additional material might be required ahead of the inquest hearing. This may include factual witness statements, independent expert evidence or the findings of a post mortem examination.
Utilise PSIRF appropriately in inquest proceedings
Although PSIRF outputs are not designed for inquests, they may still provide helpful context, particularly when a coroner is considering whether a Prevention of Future Deaths Report may be necessary.
Manage expectations with families
Families may assume that PSIRF reports will provide answers about how their loved one died. Healthcare providers should explain - sensitively and clearly - the distinction between:
the PSIRF process (organisational learning), and
the coronial process (fact finding on the circumstances and cause of death).
