Patient Safety Incidence Response Framework (PSIRF): Implementation to Impact - Mind the Gap

The Public Policy Projects Patient Safety Forum 2026 served as a powerful reminder that excellence in care is achieved through a tireless commitment to safety and QI. The networking, innovations and shared experiences made for an inspiring day. Along with Lauren Mosley, Chris Mason, and Melanie Ottewill, it was a real pleasure to engage on the Patient Safety Incident Response Framework (PSIRF) and how we move from implementation to true impact. The resounding conclusion was that it will only be through collective effort, strong leadership via engaged boards, with dedicated investigators using operationalised tools, that we will really feel the benefit of a systems-based approach to patient safety. 
 
The contributions on the day underlined the veracity of the recent HSSIB report and highlighted the ongoing friction between PSIRF and the expectations of Coroners used to the Serious Incident Framework. There was resounding agreement that it will take combined organisational effort not to ‘revert to type’ and run parallel investigations to meet and appease these expectations. In a system where ‘time’ was repeatedly highlighted as a major impediment to the successful implementation of PSIRF that would be such a retrograde step.
 
Attendees in common with interviewees contributing to the HSSIB report, spoke about having to ‘manage’ Coroner’s expectations and how this can influence the choice of learning response and whether statements are requested as part of the investigation. 
 
What we do know is that this friction is resulting in Prevention of Future Death Reports such a recent PFD from the Senior Coroner for East London citing concerns that:
 
A failure in governance at the Trust meant that this case was not identified as an incident worthy of investigation through the Patient Safety Framework. This omission gives rise to a concern that future deaths may follow due to an inability on the part of the trust to identify, reflect upon, and remediate sub-optimal practice. In this case the trust’s Datix incident reporting system, morbidity and mortality meeting process and PSIRF procedure were inadequate.
 
Another Coroner has concluded that the Structured Judgment Reviews she had seen in relation to 3 deaths were at best, poor, and at worst, defensive, warning that death investigation processes were not working well. 
 
The response from NHSE quite rightly is to highlight that PSIRF does not alter the requirements set out in the National Learning from Deaths policy framework. These require a patient safety incident investigation to be undertaken into any event where problems in care are thought more likely than not to have led to the death of a patient. The trouble with this can be that conclusions about whether there have been problems in care are only as good as the inputs. Responding to one PFD an acute provider observed:
 
“The General Surgeons recognise their process for capturing…M&M and care issues within their clinical governance minutes, has been very poor. Until April 2025, the governance minutes have been recorded by one of the administrative staff (i.e. not medically trained) without direction as to how or what to record into the minutes. Without explicit identification of learning points this has erroneously resulted in the record stating “no learning identified” even in situations where concerns were raised, learning points outlined and actions identified.”
 
So, what can we take from this and the debate during the session at the Patient Safety Forum 2026:

1. As the Chief Coroner has made clear: PSIRF does not alter the coroner’s statutory duty. The onus is on NHS and other provider organisations to ensure evidence provides assurance. 
2. Causation will need covering in evidence given to the coroner.
3. Whether it’s via a Patient Safety Event Response Meeting (PSERM) or a Patient Safety Incident Response Meeting (PSIRM) – consider what sort of learning response is indicated in the round and take practical steps to have all the information to hand; where a M&M has not yet been held, arrangements should be made to expedite this process to inform decision making around the type of learning response required in accordance with the Patient Safety Incident Response Plan. 
4. Do not overlook revisiting this decision as more evidence emerges – e.g. a family complaint. Responding to a PFD, one provider recently highlighted that their Senior Leadership Team contact families as part of the PSIRM process to ensure that a more robust review is undertaken. They have taken the view that family concerns should be a key aspect to inform decision making around the level of investigation required.
5. A decision that no PSII is required: Decision-making regarding the choice of learning response should be documented by Trusts as part of a robust governance process. Where a specific learning response is not undertaken in relation to an incident discussed at inquest, the organisation should be able to explain why this was the case.
6. Do consider in what ways and how you present your evidence and organisational learning to a coroner. If there's no PSII, how will you present the output of an MDT, AAR or huddle? This could be via a Position statement or an Organisational learning report.
7. If there is to be an overarching position statement- consider what should go in it carefully: Summarise and explain the rationale and scope of your PSIRF investigations and do not overlook including the outcome of reviews undertaken more broadly as part of your learning from deaths process; identify clearly the learning and actions arising from the PSIRF investigations and where you are with implementing a solution;
8. Compassionate engagement does not stop with the end of PSIRF process. Throughout and after the inquest the focus should be on meaningful, empathetic, and transparent involvement with families and staff affected by safety incidents. If the scope of the inquest has precluded consideration of a key family concern, consider whether the family would welcome a follow up meeting. Meanwhile staff should routinely be invited to a debrief. 

These are just a few practical considerations to bear in mind as coroners investigate deaths in a post PSIRF world. Beyond these we need to reflect on how we share the individual interventions and improvements that offer a Coroner assurance such that no PFD is required. That is the holy grail the system should aspire to.