Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development

The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to responding to patient safety incidents for the purpose of learning and improving patient safety.

HSSIB is in a unique position to contribute to understanding how PSIRF has influenced investigation practice in NHS organisations through its education and investigation functions. HSSIB receives direct feedback from hundreds of investigation leads and patient safety specialists who attend our training courses linked to PSIRF and patient safety investigation. HSSIB has also used PSIRF tools, templates and guidance in investigations which modelled an approach to investigating under PSIRF.

In addition, HSSIB has frequent contact with patient safety teams in organisations and regularly reviews incident investigation reports as part of its work. The reports provide evidence of whether a system-based approach to investigation has been undertaken, and whether there has been compassionate engagement and involvement of those affected by an incident.

Summary of learning and insights about patient safety incident investigation under PSIRF.

Applying investigation tools, templates and guidance

• The shift to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by staff.
• Using system-based tools is a skilled activity. Expertise builds over time with practice, support and guidance from those with existing expertise and experience.
• Currently there is a gap between staff’s awareness that there are tools and guides in the PSIRF toolkit and having the necessary support and expertise to be able to use them in practice.
• 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

• The principle of greater engagement and involvement in investigations is welcomed by staff and seen as the right thing to do.
• Progress towards greater engagement is variable depending on the organisational support available to enable this work.
• Time pressure was the main reason given for continuing to rely on statements from those involved in incidents rather than gathering information through interviews and discussions as recommended by PSIRF.
• Conversations which involve apologising to a patient, family or carer for harm caused during their care require specific knowledge, skills and attributes as detailed in the PSIRF patient safety investigation standards.
• 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 and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected.
• Boards and senior leaders have a powerful influence on the approach and practice of investigations.
• Some organisations have invested in implementing PSIRF and have provided the organisational support needed, for example by establishing safety teams with dedicated investigators and engagement leads, which also provide a space for sharing and learning.
• Some organisations have not invested in implementing PSIRF and progress has been limited by the lack of dedicated roles and resource. For example, some staff have attended PSIRF training in their own time as their organisation has not provided protected learning time.

External influences on investigation practice

• The lack of central funding for PSIRF implementation may have contributed to the variation in support provided within organisations to implement it.
• Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.
• Investigations involving multiple providers are difficult for a single organisation to co-ordinate.
• Integrated care boards have not always been able to provide the support and co-ordination needed for cross-provider investigations as expected under PSIRF. This means investigations often focus on one element of a patient’s journey, missing valuable learning and meaningful improvement opportunities.
• Coroners’ expectations can influence an organisation’s choice of learning response to an incident.

Other PSIRF learning responses

• Staff value having the flexibility to choose a range of learning responses to patient safety incidents.
• After action review is the chosen learning response to many incidents that previously would have triggered an investigation. It is important that facilitators are appropriately trained and that the governance processes for this learning response are robust.
• There is interest in and an aspiration to use thematic analysis but there are challenges with applying this method which mirror those of applying system-based tools.

HSSIB identified the following opportunities for NHS England to help further develop patient safety incident investigation under PSIRF. These may be done in collaboration with other organisations, including HSSIB:

• Review and refresh the PSIRF learning response toolkit, to include the use of multimedia guides, to help make the tools and guides easier for investigators to use.
• Publish examples of patient safety incident investigations which include the PSIRF system-based tools and guides used to help investigators understand their application. Examples may be particularly beneficial in sectors that may have struggled with, or be new to, implementing PSIRF.
• Support PSIRF education and training to focus on the practical application of PSIRF tools, taught by people with demonstrable expertise in applying a system-based approach and tools in investigations.
• Develop an accreditation process to assure the quality of PSIRF training.
• Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.
• Provide greater clarity on the role of PSIRF investigations and other learning responses in the coronial process to help support organisations subject to a coroner’s inquest.
• Provide guidance on the practical steps to take to decide on the most appropriate learning response to an incident, to help organisations adopt a robust, standard approach to their decision making.

Response from NHS England

The National Patient Safety Team would like to thank HSSIB for their report. As described in the report, the National Patient Safety Team are already undertaking work aligned with many of the opportunities for improvement highlighted. We have grouped the seven opportunities into four focus areas:

Opportunities to improve PSIRF training

Work includes updating the patient safety incident response standards and the PSIRF procurement framework, developing and testing in-house resources to support organisations to deliver high quality training in-house, and a review how PSIRF training aligns with the wider patient safety syllabus.

Opportunity to strengthen PSIRF oversight

In April 2025, NHS England commissioned Health Innovation East Midlands and Health Innovation West Midlands to lead work to support ICBs to deliver PSIRF oversight roles and responsibilities as well as supporting iteration and improvement of the PSIRF roles and responsibilities specification. The output of the work will inform improvements to PSIRF guidance.

Opportunity to support navigation of the intersection between PSIRF and coronial processes

The National Patient Safety Team has created a designated area on our PSIRF Futures workspace to disseminate resources related to the intersection of PSIRF and coronial processes. The team also plans to host a webinar with presentations from providers on their approach to working with local coroners.

Opportunity to improve the PSIRF Learning Response Toolkit

The National Patient Safety Team and HSSIB are working in collaboration to review the usability and design of the PSIRF Learning Response Toolkit and update as appropriate. Both organisations will hold a joint webinar to summarise the output of this collaboration.

Response received on 28 October 2025.

HSSIB identified the following opportunities for other national and local organisations to help further develop patient safety incident investigation under PSIRF:

• Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
• Support networks for knowledge sharing and collaboration for investigation staff to help foster learning about investigation practice.
• Use the patient safety incident response standards and national guidance on engaging and involving those affected to assess practice and identify where additional resource and support is needed.
• Use the patient safety incident response standards and oversight roles and responsibilities specification to assess organisational support and where further resource is needed for PSIRF implementation.
• Use the patient safety incident response standards and oversight roles and responsibilities specification in oversight processes to highlight where further support and resource is needed to meet the expectations under PSIRF.
• Increase access to education and training, focused on the application of system-based tools, and taught by people with demonstrable expertise, to help staff to carry out system-based investigations.
• Develop training in after action review and thematic analysis which includes a practical component where learners have an opportunity to apply the approach, to help ensure these learning responses are effective.