PSIRF – the road to more consistent implementation

The NHS Patient Safety Incident Response Framework (“PSIRF”) was published by NHS England in August 2022. It sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. PSIRF is a contractual requirement applicable to both the NHS and the independent sector where services are delivered under the NHS Standard Contract. It is mandatory for NHS services including acute, ambulance, and mental health. More recently a pilot has been concluded for the application of PSIRF in primary care.

On 9th October 2025, HSSIB published a report to help inform future work to support staff in system-based investigation across the NHS in England. Although the focus of the report is investigations, the learning and insights are also applicable to other learning responses under PSIRF. 

The move to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by NHS staff, but has not been without teething difficulties. Whilst interviewees for HSSIB’s report endorsed the PSIRF as being ‘a real positive’ and ‘the right way to be approaching incidents,’ the Health Service Journal has reported on seven cases – covering nine people – where coroners have issued Prevention of Future Deaths (“PFD”) reports which raised concerns that the PSIRF is producing inadequate reports or there had been no safety investigation at all. Generally, the sense is that where resources have been made available, PSIRF has had a positive impact but there remains too much system variation.

The important takeouts from HSSIB’s report are:

Investigations tools and guidance

• Using system-based tools is a skilled activity and further expertise is needed.
• Whilst there are tools available to support staff using PSIRF more support is required.
• Training for staff has provided limited opportunities for them to practically apply and discuss using the tools and guides in the toolkit.
• The current design of some PSIRF tools and guides may limit staff’s ability to use them in practice.
• Feedback indicates staff find it particularly challenging to apply the tools and guides in investigations about mental health care.

Engaging and involving those affected by patient safety incidents

• Greater engagement and involvement in investigations is welcomed by staff but progress towards achieving this is variable.
• Time pressure means continued reliance on statement gathering as a means of investigating rather than gathering information through interviews and discussions as recommended by PSIRF.
• Conversations which involve apologising to a patient, family or carer for harm require specific knowledge, skills and attributes.
• Specific challenges in engaging with patients, families and carers were highlighted in investigations in mental health organisations.

Organisational support for patient safety incident investigation

• Organisational support is essential when making the shift to a system-based approach to investigation with meaningful involvement of those affected, which should be led by Boards.
• Practice is variable but establishing safety teams with dedicated investigators and engagement leads, providing a space for sharing and learning, is seen as important in successful implementation.

External influences on investigation practice

• Lack of central funding for PSIRF implementation may have contributed to the variation in implementation.
• Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency.
• Investigations involving multiple providers are difficult for a single organisation to co-ordinate.
• ICBs have struggled to provide the support and co-ordination needed for cross-provider investigations as expected under PSIRF
• Coroners’ expectations can influence an organisation’s choice of learning response to an incident.

Other PSIRF learning responses

• Staff value the flexibility to choose from a range of learning responses to an incident.
• After action review (“AAR”) is the chosen learning response to many incidents but needs proper training for the staff leading the review.

The HSSIB report develops a number of recommendations which include:  

• Refresh the PSIRF learning response toolkit, to include the use of multimedia guides.
• Develop an accreditation process to assure the quality of PSIRF training.
• Provide details of the support and resource expected from ICBs to facilitate cross-organisational investigations.
• Provide greater clarity on the role of PSIRF investigations and other learning responses in the coronial process to help support organisations involved with a coroner’s inquest.
• Create support networks for knowledge sharing and collaboration for investigation staff to help foster learning.
• Increase access to education and training, focused on the application of system-based tools.
• Develop training in AAR and thematic analysis which includes a practical component where learners have an opportunity to apply the approach.

PSIRF is a major step towards improving safety management across the healthcare system in England and is supporting the NHS to embed the key principles of a patient safety culture. It will ensure the NHS focuses on understanding how incidents happen, rather than apportioning blame on individuals, allowing for more effective learning and improvement, and ultimately making NHS care safer for all. But there is more to be done. In short, more funding, practical resources and increased oversight are needed to enable PSIRF to deliver on its potential and for consistent implementation across the system to be achieved; what we cannot get too distracted by is PSIRF’s ability, via its learning responses, to help when it comes to the statutory function of a Coroner. PSIRF fulfils a different role to the statutory function of a Coroner.