Organisations were expected to transition to the Patient Safety Incident Response Framework by the autumn of 2023. Its effects are already being felt.
The Patient Safety Incident Response Framework (PSIRF) is a part of the NHS Patient Safety Strategy, which was first published in July 2019. It was created to help healthcare organisations examine serious incidents without fear of inappropriate sanctions. At the same time, it was set up to support those people affected, with the ultimate aim of improving services by focusing on patient safety.
PSIRF has replaced the Serious Incident Framework. Crucially, the PSIRF framework makes no distinction between patient safety incidents and serious incidents. This is not an attempt to gloss over the issue, rather it is an attempt to promote a proportionate approach to responding to patient safety incidents by ensuring that resources allocated to learning are balanced with those needed to deliver improvement.
“Hospitals previously operated under a framework known as the Serious Investigation Framework. This framework allowed hospitals to conduct investigations following patient incidents. However, both hospitals and NHS Resolution found that under this system, every type of incident – regardless of its scale or significance – was being investigated,” Nina Vagad, lead healthcare investigator at TMLEP, told Healthcare Today.
The PSIRF approach is meant to be flexible and it adapts as organisations learn and improve, so they explore patient safety incidents relevant to their context and the populations they serve.
It is about “changing the culture from individual blaming to one that is just and acknowledges systematic failings,” said Jodi Newton, partner in medical negligence, at Osbornes Law.
Compassionate engagement
At the heart of the new framework is what Katie Viggers, professional development lawyer at Browne Jacobson, calls the “compassionate engagement and involvement of those affected by patient safety incidents”.
Organisations are required to develop a thorough understanding of their patient safety incident profile, ongoing safety actions and established improvement programmes. To do so, information is collected and synthesised from a wide variety of sources, including wide stakeholder engagement.
What is key is a considered and proportionate response to patient safety incidents.
Organisations were expected to transition to PSIRF by the autumn of 2023 and it is mandatory for all services provided under the NHS standard contract. This includes all NHS acute, ambulance, mental health, community, maternity and specialised services as well as any private healthcare providers who deliver services under the NHS standard contract.
Preparation, governance structure and stakeholder engagement
Derbyshire Healthcare NHS Foundation Trust was one of the first Trusts to implement PSIRF.
Andrew Coburn, assistant director of legal, governance and mental health legislation at the Trust said that “getting the terms of reference right is key”.
The Trust took a three-pronged approach to implementation: preparation, governance structure and stakeholder engagement.
To begin with, an external company was engaged to deliver training to staff which focused on changing mindset and highlighting that “PSIRF looks at the ecosystem around an incident rather than the incident itself”.
Governance structure, he said, was “more important than the Trust initially realised”.
The Trust set up a governance operation team to review incidents within 72 hours. It then moved to the oversight group executive committee chaired by the medical director to scrutinise all learning responses. Finally, the patient safety team formats the response and the family liaison team scrutinises it for suitability for the family.
As for stakeholder engagement, the Trust has, Coburn said, taken “a collaborative approach” with the coroner.
The family liaison team make contact with the family after a serious incident outlining the response the Trust will be undertaking in terms of a learning review from their loved one’s death. For case record reviews, the coroner receives the whole report. Families receive a letter highlighting the salient points and conclusion as it is easier to digest.
For immediate learning concerns, what Coburn calls “a blue light” goes out to everyone as an emergency learning response.
The Trust has a periodic learning-the-lessons meeting with patient safety and operational leads to review the actions that have arisen since the last review.
Crucially, Coburn said, there is a need to be flexible. “A learning response may need to be upgraded if the facts start to suggest more learning can be obtained,” he said. And the Trust should engage with the family as soon as possible to manage expectations.
A considerable shift
Much like the Serious Incident Framework, PSIRF is expected to remain current for the next ten to 15 years.
Since the deadline to transition in PSIRF, there has been what Rebecca Sharrock, healthcare specialist and partner at Hill Dickinson in Manchester, calls “a considerable shift” to the way in which the NHS responds to incidents relating to patient safety.
There has been increasing engagement and involvement with those affected by patient safety incidents. Some Trusts have gone so far as to implement additional technology, in the form of incident trackers, which allow all staff involved in patient safety investigations to monitor engagement with families throughout the process.
The flexibility of approach to serious incidents has also been noted, specifically the move away from the need to investigate every incident in that it was previously. It should be noted that there has been no shift away from the inquest process.
“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,” Sharrock said.
The changes that have happened will inevitably still take some time to get used to. But the move itself is not difficult to understand.
“If healthcare organisations cannot objectively demonstrate an improvement in their safety record – or a reduction in the kinds of horrific inquiries and scandals that seem to arise every few months – then those responsible for implementing these frameworks will need to address this directly,” said Neil Rowe, senior in-house counsel at THEMIS Clinical Defence.
“This heightened focus on measurable outcomes and transparent explanations is precisely why the new framework was introduced. It aims to ensure that improvements in patient safety are not just theoretical but are demonstrable and meaningful in practice,” he concluded.
