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.

This report contains learning and insights gathered from interviews with HSSIB investigators and educators. The report identifies opportunities to develop patient safety incident investigation under PSIRF.

• 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.

• 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 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.

• 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.

• 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:

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

Adopting a system-based approach to investigations

2.1.1 PSIRF promotes a system-based approach to learning from patient safety incidents. A system-based approach uses tools and methods which draw on a scientific discipline called Human Factors or Ergonomics. This discipline seeks to identify the interactions between people and other elements of a work system (such as the equipment, technology and environment) and to understand how these influence or contribute to outcomes including patient safety incidents. A toolkit of investigation tools, templates and guidance is available to help NHS staff carry out investigations and other learning responses with this system focus.

2.1.2 Interviewees consistently said they had received positive feedback from NHS staff about the shift to a system-based approach. In particular, NHS staff liked the fact that this approach avoided blaming individuals when incidents happened.

2.1.3 Interviewees thought it was helpful to have a toolkit for NHS staff. However, they said feedback from NHS staff highlighted challenges with applying the tools in practice.

2.1.4 Interviewees said that there was limited understanding and expertise among staff in applying system-based tools. Interviewees from HSSIB’s education team said most NHS staff attending courses had had no previous training, or any opportunity to practise applying the tools with a mentor with existing expertise to support them as they developed their skills. The comments received during interviews indicated that without these elements in place, it was unrealistic to expect NHS staff to use the tools. This means that the capacity for the tools to drive improvements is limited and their potential is only likely to be fully realised in organisations where the necessary support is in place (see section 2.3, ‘Organisational support for patient safety incident investigations’).

2.1.5 Interviewees said there were additional challenges for staff in mental health organisations applying the tools in their investigations. From the interviews there was limited evidence of the tools being used. Interviewees said their conversations with NHS staff (through HSSIB’s education courses or investigations) indicated uncertainty about if, or how, the tools could apply in the incidents commonly investigated in mental health organisations. For example, in incidents involving suicide and self-harm understanding ‘why’ things happened (that is, why someone may have chosen to harm themselves) may not be known in the same way that may be possible for other incidents.

2.1.6 HSSIB’s systems approach course fulfils PSIRF training requirements for learning response leads. At the time of writing this report (July 2025) 21,952 NHS staff have enrolled on the course and 6,598 have completed all the modules. The course was set up to provide an introduction to systems thinking and system-based investigation, rather than to provide a deep level of learning and to equip people to apply tools unaided in practice. As such, the course was not intended to provide NHS staff with the opportunity to meaningfully assess their knowledge, or to experiment and assess their use of tools in practice.

2.1.7 Interviewees who facilitate HSSIB’s support sessions that accompany the course said their conversations with NHS staff showed that for the majority this was their only training in system-based investigation and system-based tools. Despite the limitations of current training, interviewees said it was unusual for NHS staff to have the help of skilled mentors, or those with expertise, to oversee, guide and support them when using the tools in practice.

2.1.8 In response to this feedback, HSSIB is developing courses which provide the opportunity for NHS staff to practise applying system-based frameworks and tools. Interviewees who teach the first course developed (about a systems framework called the Systems Engineering Initiative for Patient Safety (SEIPS)), said it was typically the first time NHS staff had applied the framework with skilled oversight of its use. In addition, the updated procurement framework for PSIRF training (due to be published in November 2025) puts greater focus on learning outcomes and practical application. NHS England’s Patient Safety Team advised HSSIB that the intention is to update the training standards to reflect this focus.

Using the Systems Engineering Initiative for Patient Safety (SEIPS) framework

2.1.9 SEIPS is a system-based framework for understanding outcomes in healthcare. The framework draws on Human Factors/Ergonomics principles and includes six broad elements (external environment, organisation, internal environment, tools and technology, tasks and person(s)) which all influence how work is done. The framework prompts consideration of the interactions between the different elements to help understand the outcomes (including incidents) that result. The PSIRF patient safety learning response toolkit encourages the use of the SEIPS framework to explore the system factors that contributed to a patient safety incident.

2.1.10 Interviewees told us that NHS staff working in patient safety are now familiar with the term ‘SEIPS’. They said that staff often talk about, and mention in their investigation reports, using this framework to support a system-based approach.

2.1.11 Interviewees who teach HSSIB’s SEIPS in action course said that more in-depth conversations with NHS staff showed that while they had acquired “the language” of a systems approach, for most NHS staff there was a gap in understanding and a “superficiality of application” of SEIPS.

2.1.12 Interviewees pointed out that using SEIPS (or any of the system-based tools) is a skilled activity and, like other skilled activities, expertise builds over time and with insightful, constructive feedback and oversight by those with existing expertise and experience. The tools themselves, and guidance, cannot replace or remove the need for this learning process. For example, the guidance on SEIPS in the toolkit does not, on its own, enable staff to understand interactions or how to prioritise themes relating to work system elements. Those new to SEIPS, and without the benefit of constructive guidance, tend to “categorise into isolated elements of a work system” or “buckets”.

2.1.13 Interviewees said that, while there were some exceptions, this novice and superficial use of SEIPS was evident from some investigation reports shared with HSSIB that had included SEIPS diagrams.

The patient safety incident investigation (PSII) report template

2.1.14 Interviewees said the report template seemed to be in use in all NHS organisations. Interviewees from HSSIB’s education team pointed out that some organisations had started using the template sooner than others, meaning some NHS staff had more experience of using it, and were more familiar and comfortable with the structure. Interviewees who teach the HSSIB course on writing effective learning reports said the feedback from NHS staff was generally positive, specifically about the fact that there was a template and that it included guidance notes for use.

2.1.15 Interviewees said NHS staff described there being some repetition of information – for example, information in the executive summary being repeated at the end of the report. This meant duplication of effort for the writer of the report and, for both the writer and reader, additional time and effort spent on the report.

2.1.16 Interviewees said that some NHS staff on the writing effective learning reports course were uncertain about what to include in certain sections and, in particular, how to structure and write the ‘Findings’ section of the report. Interviewees reflected that being given flexibility to decide how to organise this section meant some NHS staff were unsure about what to do.

2.1.17 Interviewees who had reviewed reports shared with HSSIB that were written using the PSII template said that it was not easy to make comments on the report as the sections and paragraphs are not numbered. They thought including numbering in the template may make it easier for NHS staff, patients, families and others to give feedback.

2.1.18 Interviewees who had written reports using the template said that after writing the ‘Description of the patient safety incident’ (that is, ‘what’ happened), there is the ‘Investigation approach’ section which has several sub-sections before you get to the ‘Findings’ section. This means those reading the report have to wait, and can have a lot of information to read, before getting to the ‘why’ of what happened and what is going to be done about it. This may be frustrating for patients and families.

2.1.19 Interviewees also commented on the formatting of the PSII report template. For example, some of the text boxes in the report were formatted as a group which meant which meant staff had to spend time trying to undo the formatting to move boxes around when writing the report.

2.1.20 Interviewees said there was variability in the content of the reports shared by organisations with HSSIB as part of investigation activities. Interviewees gave examples of excellent reports which had included lots of analysis with evidence of a system-based approach taken. By contrast, they gave examples of other reports where there was little analysis, and the ‘Findings’ section contained more of the ‘what’ happened rather than the ‘why’.

2.1.21 Interviewees from both HSSIB’s education and investigation teams told us that NHS staff had said it would be helpful to have more published examples of PSII reports, set in different care settings (acute care, mental health, community) so NHS staff could easily access example reports to refer to as a benchmark and guide. In response to this, HSSIB published three example PSII reports on the subject of sepsis in June 2025. HSSIB also plans to publish further PSII reports in relation to mental health care.

Tools and guides for planning, synthesis and exploring everyday work

2.1.22 The patient safety learning response toolkit includes four tools to help in the initial stages of an investigation or other learning response; four guides to support the exploration of everyday work; and two tools to assist with synthesis of information.

2.1.23 Interviewees from HSSIB’s education team said they had received very little feedback from NHS staff on courses about use of these tools or guides. They were uncertain if these were being used in practice; if so, based on the absence of feedback or discussion about them, using them seemed to be the exception rather than the rule.

2.1.24 Interviewees from the investigation team said that, based on their interactions and conversations with NHS staff during investigation activities, there was limited evidence of these tools and guides being used in practice. The exception to this was a few organisations where there were NHS staff with human factors/ergonomics expertise and/or prior expertise is using system-based tools. In these organisations, interviewees had seen evidence of efforts to understand everyday work (such as conducting observations) and other tools being used as part of investigations.

2.1.25 Related to the limited use of tools, interviewees from HSSIB’s education team said that from conversations with NHS staff attending HSSIB courses, most did not know when it might be appropriate to use the different tools. That is, they did not know in what circumstances it might be better to use one tool over another, or what insights one particular tool might give them compared to another tool. Again, interviewees highlighted the need for a depth of underpinning knowledge about a system-based approach and the chance to experiment with others developing expertise, supported by constructive oversight and mentoring.

2.1.26 Interviewees who had used the tools and guides in the toolkit in HSSIB’s investigations under PSIRF gave feedback about the formatting and content of them. For example, one of the tools to help with the initial stages of an investigation is a guide and template for crafting terms of reference. Interviewees who had used the guidance said that the inclusion of ‘healthcare settings’ and ‘healthcare processes’ for each and every term of reference meant they were repeating and duplicating information. They thought it may be beneficial for the template to give the flexibility for the investigator to decide whether it was necessary to include for each term of reference, or whether to list these just once for the collective terms of reference.

2.1.27 Interviewees who had used the work system scan tool said the formatting meant you could not freeze relevant information/columns. In addition, they described having to repeat information, which they thought may deter busy staff from using it. They also found the explanatory descriptions of the work system factors to be very formal, and interviewees thought that writing them in plain English would make the tool easier to use.

2.1.28 Interviewees also commented on the stakeholder map. They said the formatting was bigger than a standard slide. Amending the formatting to a standard slide size, or putting it in a different format to PowerPoint, may make it easier to use. Interviewees also said that the inclusion of healthcare processes in the map meant it became a very busy slide, especially when there were multiple providers to include.

2.1.29 Interviewees thought that having some examples of the completed tools in published PSII reports may be helpful for staff so they could see how they supported planning, synthesis and exploring everyday work.

2.1.30 In addition, interviewees said that multimedia guides showing how to use the tools may be beneficial. For example, one interviewee pointed out the way YouTube videos can help understanding of practical tasks and the application of tools. They pointed out the potential of this medium to help staff use the tools by demonstrating how they can be applied in specific scenarios. The interviewee said this medium may provide greater insight and immediacy than is possible with written guides.

Developing safety actions

2.1.31 PSIRF states that investigations and other learning responses should identify ‘areas of improvement’ or system issues where changes to the work system could reduce risk and potential for harm. Actions to reduce risk (‘safety actions’) are then generated in relation to each area of improvement.

2.1.32 The toolkit contains a safety action development guide which includes information about how to define areas of improvement. For example, the guide says that areas of improvement should not give specific solutions and should ‘provide an opportunity for a range of safety actions to be considered’.

2.1.33 HSSIB’s investigations under PSIRF identified areas of improvement for local NHS organisations to develop safety actions to address. Interviewees involved with these HSSIB investigations had used the guide to develop the areas of improvement. They said the feedback from NHS England on these investigations showed that getting the balance right, so the areas of improvement were not so broad in scope as to be unhelpful, but not so narrow in focus as to be, in effect, solutions, was not straightforward. One example of an area of improvement is provided in the safety action development guide but interviewees said more published examples of investigations under PSIRF with identified areas of improvement may be helpful for staff.

2.1.34 The toolkit also contains a debrief tool to help NHS staff engage teams and those affected by the learning and outcomes of an investigation or other learning response. Interviewees from HSSIB’s education and investigation team did not have any information about use of this tool. They had not received feedback about it from NHS staff attending HSSIB courses and/or through conversations during investigation activities.

The learning response review and improvement tool (LRRT)

2.1.35 The learning response review and improvement tool (LRRT) was developed by NHS Education for Scotland and subsequently refined by NHS England and HSSIB. A link to the tool is included in the PSIRF toolkit.

2.1.36 Interviewees said the LRRT was often mentioned by staff attending courses, indicating it was being widely used. Interviewees from the education team said staff described the tool as providing a mechanism for those in oversight roles to constructively review and comment on reports, as well as acting as a “checklist” for those writing reports.

2.1.37 Interviewees who teach HSSIB’s course on writing effective learning reports, which includes discussion about the LRRT, reflected on why this tool might be used more than other tools and guides in the toolkit. They pointed out that the LRRT does not require the training and expertise needed to use the other system-based tools. The LRRT contains eight areas of review which are explained and can be used to assess a report. The tool can be picked up and used straight away: “there’s almost no kind of like outlay at the front”. In addition, the LRRT has a useful and “clear purpose” in oversight of reports and as an aid to report writers.

Summary

2.1.38 The shift to a system-based approach to investigation, which avoids blaming individuals when incidents happen, has been positively received by staff.

2.1.39 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.

2.1.40 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.

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:

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

2.2.1 Guidance on how organisations should engage and involve patients, families and staff following a patient safety incident has been published alongside PSIRF. The guidance details the organisational support, in terms of systems and processes, that needs to be in place to create the ‘right foundations’ for engagement work. It also describes what it means in practice to compassionately engage and meaningfully involve those affected by patient safety incidents throughout an investigation or other learning response.

2.2.2 Interviewees said that the move to greater engagement and involvement was welcomed by NHS staff, who believed it was the right thing to do and valued the emphasis given to it in PSIRF. However, feedback from NHS staff on HSSIB courses indicated that progress in practice in this area was variable and dependent on the organisational resources and support in place.

2.2.3 This feedback was mirrored in the experiences of interviewees from the investigation team who had worked closely with learning response leads during investigations and/or read PSII reports from different organisations across England. For example, although engagement processes were not reviewed, some PSII reports included the views and comments of patients, families and staff throughout the report, so it was clear they had been met with and involved. In other reports this voice was absent or “in the background”, suggesting there had not been the same level of involvement.

Staff engagement and involvement

2.2.4 Interviewees from HSSIB’s education team gave examples from NHS staff attending HSSIB courses who had made significant changes in the process of staff engagement and involvement since PSIRF. For example, having previously asked staff for statements, they now interviewed them in person as recommended in PSIRF supporting guidance. In addition, some organisations had developed information resources (written material and videos) to share with staff to explain the investigation process, to make clear the focus on learning and to advise them of avenues of support. Furthermore, the language surrounding investigation had changed to make the process less anxiety-provoking – using the word ‘meeting’ rather than ‘interview’, and ‘care review’ rather than ‘investigation’.

2.2.5 Interviewees teaching HSSIB’s course on involving those affected by incidents said that time pressure was the main reason given by NHS staff for continuing to rely on statements for investigations. The time commitments associated with interviews rather than statements are multiple: arranging a date and time that suits both interviewer and interviewee; organising a suitable venue; and conducting the interview itself. This time pressure was a particular issue for NHS staff whose primary job was something other than investigation and who were fitting in information gathering around their main job.

2.2.6 In contrast, we were told of examples of organisations where statements were requested or where there was a mix of both statements and interviews. Similarly, interviewees from the investigation team shared examples where they had investigated an incident previously investigated by the organisation, and NHS staff they met with had not been interviewed before, or had any support or engagement by the organisation’s investigation leads.

Patient and family engagement and involvement

2.2.7 Interviewees described the same variability in relation to patient and family involvement in investigations. Again, positive examples were given of organisations that had invested in this area by supporting investigators to build expertise, or employing dedicated family liaison staff, along with developing resources to support engagement and involvement.

2.2.8 Those teaching HSSIB’s course on involving those affected by incidents told us that NHS staff who talked about current practice in their organisations said they were offering to meet patients and families in their home (or at a place of their choosing) and described a greater level of involvement now than before PSIRF. However, they pointed out that many attending courses did not provide feedback, so it was not possible to know how common this good practice is.

2.2.9 Examples were also shared of experiences and staff feedback which indicated that in some organisations little if anything had changed since the introduction of PSIRF. It was described that in some organisations, involvement consisted of telling the patient or family about an investigation as required by the duty of candour and then sharing the report at the end of the investigation as a finished product, with no meaningful involvement taking place.

2.2.10 Interviewees said that, as with staff engagement, time was an important barrier. Limited expertise was another – particularly in organisations that did not have dedicated investigators and/or engagement leads and the role of family engagement lead was an add-on to a person’s main job (often a clinical role). Interviewees pointed out that clinical conversations are different to those which involve apologising for harm caused during a patient’s care. These require specific knowledge, skills and attributes as detailed in the PSIRF patient safety incident response standards. Feedback from NHS staff affirmed the need for those leading engagement work to have the opportunity to build expertise and to share and learn with others doing this work.

2.2.11 In addition to having dedicated, trained engagement leads, interviewees reported other forms of organisational support that made clear the priority of this work. For example, in some organisations, members of the executive team took part in patient and family meetings that were complex or difficult. This gave them a detailed understanding of the demands of the work, as well as providing practical help for engagement leads. Another example was putting in place formalised support structures to develop engagement leads, such as mentoring, buddying, networking and facilitated debriefing.

2.2.12 Interviewees who carried out HSSIB’s investigations in mental health inpatient settings said that, based on this work, there were some specific challenges associated with engaging with patients and families in these settings. Incidents relating to mental health care, particularly where a patient has died, can be especially emotive and complex. Examples were given of NHS staff experiencing blame and criticism which had created a fear of engagement with families. The information from interviewees suggested that mental health organisations may need some more targeted support and guidance given the challenges they face. HSSIB’s report on learning from deaths in mental health inpatient services describes issues with engagement in some mental health investigations, and the consequences in terms of compounded harm.

Examples of variation in engagement and involvement of staff, patients and families

2.2.13 HSSIB’s investigations under PSIRF demonstrated the variation in engagement and involvement of those affected and the different ways organisations manage and organise this work.

• In one investigation, which involved an incident that had previously been investigated by the organisation, the NHS staff involved had not been interviewed and there was very limited family involvement in the investigation. The staff engagement lead was someone whose primary role was clinical. The family engagement lead was a different person, and their primary job was also not investigation or engagement. They had been asked to lead because they had responsibility for nursing care in the clinical speciality where the incident had happened.
• In one investigation, a family liaison officer engaged with the family, but they were unable to provide answers about the investigation and the family described this person as creating another layer or “middleman” they had to go through to try and get answers. There were two dedicated investigators in the organisation but due to sickness of the allocated investigator the investigation did not progress until HSSIB became involved.
• In one investigation, there was good engagement with staff, the patient and their family. The engagement leads had dedicated patient safety roles with investigation and engagement as key elements of their roles.

Summary

2.2.14 The principle of greater engagement and involvement in investigations is welcomed by staff and seen as the right thing to do.

2.2.15 Progress towards greater engagement is variable depending on the organisational support available to enable this work.

2.2.16 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.

2.2.17 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.

2.2.18 Specific challenges in engaging with patients, families and carers were highlighted in investigations in mental health organisations.

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

2.3.1 The PSIRF standards for the response to patient safety incidents acknowledge the organisational support needed for NHS staff to have the necessary competence and capacity to carry out PSIRF investigations and other learning responses.

2.3.2 The organisational buy-in needed for investigation (and other learning responses) and engagement to be effective is also acknowledged in the PSIRF guidance on oversight. The questions in this guidance for NHS organisations to consider address the different elements of organisational support needed for the patient safety incident response standards to be met.

2.3.3 Interviewees were unanimous that organisational support and informed oversight were fundamental and essential to enable the shift to a system-based approach to investigation with compassionate involvement of those affected.

2.3.4 PSIRF’s patient safety incident response standards set out how organisations should support PSIRF learning response leads. For example, leads should have ‘dedicated paid time to conduct learning responses’ and there should be ‘dedicated staff resource to support engagement and involvement’ of those affected by incidents. Based on NHS staff feedback, organisational support, in practice, meant:

• having dedicated investigators and engagement leads (either separate to or part of an investigator role) who were given time for training, access to expertise while developing their skills, and network opportunities
• senior and executive leaders who had a “systems mindset”, understood what a system-based investigation meant and where the leadership team was set up to act on the findings
• senior and executive leaders who understood what compassionate engagement and meaningful involvement of those affected meant in practice
• oversight of PSIIs which gave constructive feedback
• using available mechanisms and structures to demonstrate that a systems approach to investigation and meaningful involvement was a priority.

2.3.5 Interviewees said that NHS staff feedback showed there was considerable variation between organisations in all these aspects which, in turn, meant there was considerable variation in investigation practice, and in the engagement and involvement of those affected. Interviewees said that some NHS staff who attended HSSIB courses reported they were taking the course, and completing investigations, in their own time. Time was described by interviewees as “one of the biggest challenges” to taking a system-based approach to incident investigations and meaningful involvement of those affected.

2.3.6 In some organisations there had been significant investment in the establishment of multidisciplinary safety teams, including both clinical and non-clinical NHS staff as well as human factors/ergonomics expertise, to facilitate the shift to a system-based investigation approach. Protected learning and investigation time had been made available and having a dedicated safety team provided a space for sharing, reflection and learning. In other organisations, there had been little investment in this area with investigations allocated to those with other roles (often clinical). These NHS staff often had very limited time, training, experience or expertise in system-based investigation or how to meet PSIRF expectations about engaging and involving those affected by incidents.

2.3.7 Boards and senior leaders were described as having a powerful influence on investigation approach and practice in an organisation. This influence was affected by both their personal professional interest and understanding of current thinking about safety investigation and involvement of those affected by incidents, as well as the priority they gave to this work in terms of resources.

2.3.8 Interviewees shared a comment made by a member of NHS staff at one of the sessions to support those undertaking HSSIB’s systems approach course. They had described a difficult disconnect between what they were being taught about a systems approach to investigation and wanted to implement, and what their organisation wanted. Other NHS staff at the session had agreed it was an issue. Similarly, interviewees gave examples of NHS staff saying that they had to write reports their organisations would accept, which meant only including findings, areas of improvement or recommended safety actions that were internal and could be achieved or “fixed” in a short timescale.

2.3.9 Summing up the situation for NHS staff in organisations where the necessary support for a systems approach and meaningful involvement is lacking, interviewees said their impression was that it could be “a lonely existence”:

Summary

2.3.10 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.

2.3.11 Boards and senior leaders have a powerful influence on the approach and practice of investigations.

2.3.12 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.

2.3.13 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.

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

2.4.1 PSIRF sets expectations for how NHS organisations should investigate incidents and engage and involve those affected. External factors can help or hinder how policy is implemented in practice. Interviewees gave examples of external factors that influenced and/or created challenges for NHS staff leading investigations and other learning responses.

Financial support

2.4.2 PSIRF was introduced without central financial support for organisations to implement it. Interviewees said the consequences of this are reflected in the differing priority and allocation of resources for PSIRF. They emphasised the imperative for dedicated resource for investigation and engagement work and said that without central funding to enable organisations to meet the expectations set in the PSIRF patient safety incident response standards variation was inevitable, particularly given the financial pressures and competing priorities organisations faced.

2.4.3 Interviewees commented on the national review of patient safety and announcements to rationalise the patient safety landscape and reduce costs. Interviewees were concerned about how this might impact on the support available for effective implementation of PSIRF, particularly given changes in the role and structure of NHS England.

External oversight

2.4.4 PSIRF supporting documents includes guidance that sets out oversight roles and responsibilities. Integrated care boards have a key role as they have responsibility to ‘agree provider patient safety incident response plans’, ‘oversee and support effectiveness of systems’ and ‘support co-ordination of cross-system learning responses’.

2.4.5 Interviewees said there appeared to be a lack of oversight of PSIRF implementation, particularly in terms of knowing whether and how system-based investigation and engagement is being supported appropriately in organisations. Interviewees queried who was best placed to do the oversight needed and what exactly the expectation would be. NHS staff feedback, particularly from interviewees involved with Patient Safety Specialist training, was that external oversight from integrated care boards was “patchy”.

2.4.6 Interviewees who teach HSSIB’s patient safety incident response oversight course said they observed “uncertainty and anxiety” in those in oversight roles. Reflecting on this, one interviewee pointed out that the flexibility provided by PSIRF, and the change in the nature of oversight, meant it was less clear what to do.

2.4.7 Under PSIRF, organisations are asked to work with their integrated care boards to design processes for oversight. This could include sharing incidents and investigation reports, but this is not a requirement as it was under the previous framework. Interviewees said integrated care boards described feeling more detached from their organisations as a result, and less knowledgeable about incidents and investigations being undertaken. These concerns were also identified in HSSIB’s investigation about safety management: accountability across organisational boundaries.

2.4.8 Interviewees said NHS staff in organisations were aware that some integrated care boards did not like the fact that they were not routinely receiving investigation reports and said that some did not like the range of learning responses possible under PSIRF. Interviewees said it seemed that receiving lots of serious incidents reports, as they had under the previous serious incident framework, gave a perception of “insight about what was happening in trusts … it gave them some sort of comfort or reassurance”.

2.4.9 Interviewees said that those working in integrated care boards had pointed out the challenges they faced in providing meaningful oversight – specifically, limited time and resources. For example, integrated care boards are responsible for many different organisations, and interviewees said that while attending PSIRF meetings seemed reasonable in principle, in reality they did not have the time to do this.

2.4.10 HSSIB’s report on safety management: accountability across organisational boundaries provides further evidence of the challenges faced by integrated care boards in meeting national expectations. The report identified resourcing as a key issue and usability of safety data as a further challenge.

2.4.11 Interviewees said the Department of Health and Social Care reforms to the structure and role of integrated care boards, and the requirement to cut running costs by 50%, is likely to exacerbate and put at risk the already patchy oversight and support they provide for PSIRF implementation. Interviewees pointed out the need for identified support and clarity about the detail of oversight responsibilities if the potential of PSIRF in terms of system-based investigations and engagement of those affected is to be realised.

2.4.12 NHS England told us that it has commissioned the Health Innovation Network South London to look at oversight by integrated care boards. It said this will help inform any changes or additional support required.

Procurement of and access to investigation training

2.4.13 The PSIRF patient safety incident response standards acknowledge the training requirements needed to meet its aims of system-based investigations and compassionate engagement. HSSIB provides free training to NHS staff but demand for places outstrips the places available for some of the PSIRF-related courses. A procurement process identified other providers that, based on a criteria set, were endorsed as providing appropriate PSIRF-related training. Organisations may choose to buy training from these providers as well as, or instead of, accessing HSSIB training. NHS England are due to publish a new procurement framework in November 2025 for providers of PSIRF training.

2.4.14 Interviewees told us that staff described challenges with the training requirements. These challenges related to having protected time for learning (see section 2.3 on organisational support for patient safety incident investigation); the cost of training not provided by HSSIB; and the variable quality of training by private providers – specifically, the need for those facilitating courses to have expertise in system-based investigation and compassionate engagement.

2.4.15 Interviewees said that staff gave positive feedback about HSSIB courses but the high demand for them meant it was hard to secure a place. Staff reported courses often being fully booked within minutes of being released. The exception to this is HSSIB’s flagship course on a systems approach to investigations and learning from patient safety incidents which is a self-paced, online course of recorded modules for learners to complete within 6 months. Interviewees said that despite this timeframe, some staff still struggled to complete the course. This was particularly the case if investigation and engagement was an add-on to their primary role so was being done in, around and on top of their main role.

2.4.16 The procurement framework for PSIRF training does not include a monitoring or accreditation process, which means training received by staff (including from HSSIB) is not accredited. NHS England said the new framework includes some additional requirements to help ensure the quality of training delivered, for example, sending out surveys to get feedback on training purchased from private providers. In addition, assessors of training applications have the ability to request and review information submitted in support of the provider’s application and/or a sample of course materials, and a sample of course attendee feedback.

2.4.17 Interviewees raised concerns about assuring the quality of training without an accreditation process. Although this does not currently exist, NHS England said they intend to explore introducing an accreditation process for training in the future.

Investigations across multiple organisations

2.4.18 PSIRF recognises the need for processes to be in place to facilitate investigations that span multiple organisations. Interviewees said that NHS staff described these investigations as too difficult to co-ordinate and manage in practice meaning they were rarely carried out.

2.4.19 PSIRF guidance on oversight and patient safety incident response standards state that integrated care boards should provide the necessary support to co-ordinate these investigations. Interviewees said that NHS staff reported that in reality this support was often not offered or possible. Interviewees said those attending HSSIB courses had provided occasional examples of when integrated care boards had become involved and taken a co-ordination role. On those occasions it had proved very helpful and generated richer learning, but more generally staff described a “hands off” approach.

2.4.20 HSSIB’s report on safety management: accountability across organisational boundaries found challenges to integrated care boards co-ordinating and supporting investigations in line with national expectations. For example, some integrated care boards described having limited capacity to undertake investigations. In addition, some said they did not have the skillset to undertake complex system-wide investigations that involved multiple providers.

2.4.21 Interviewees highlighted the lost opportunity for learning if investigations do not involve all the organisations involved in an incident. In addition, there is the risk of duplication and wasted effort if other organisations are investigating the same incident but only looking at their role in the incident, or one particular aspect of it. Furthermore, there is a lost opportunity to share learning; this leads to insight being retained, and improvements made, solely in one organisation when they may be applicable to many.

2.4.22 Interviewees gave examples of investigations carried out by organisations which had focused on isolated sections of a patient’s journey, leading to improvements that may not address the more systemic contributory factors. Interviewees shared their experience of an HSSIB investigation into an incident that had previously been investigated by the organisation where the incident happened. They described how the organisation’s focus on just one element of the patient’s journey had resulted in inappropriate areas of improvement being proposed that added to ‘safety clutter’ rather than addressing the system issues. Interviewees said ‘silo’ working was also evident in some integrated care boards. For example, the interviewees involved in HSSIB’s investigations into medication-related harm said that two integrated care boards which adjoined each other did not know or have details of each other’s patient safety teams.

2.4.23 HSSIB’s investigations under PSIRF involved multiple providers. Interviewees who carried out these investigations described the additional time needed when there are multiple safety teams to contact and interviews to be arranged with staff from multiple teams. In addition, interviewees described organisations as having differing levels of investment in, and commitment to, an investigation depending on various factors – for example, how they perceived their organisation’s role in what had happened, and how they perceived the incident itself.

Coroners

2.4.24 Coroners, and their influence, were raised by all interviewees. They said NHS staff feedback indicated that there was variable understanding among coroners about PSIRF, and not always an acceptance that an incident may lead to a learning response that was not an investigation.

2.4.25 Interviewees gave examples of a few organisations that had very good relationships with their coroner(s) and where an understanding had been reached about PSIRF and its effect on the number and focus of investigations. However, interviewees typically spoke about “frustration” described by NHS staff and difficulties for organisations trying to “manage” coroners’ expectations and wishes.

2.4.26 Interviewees said that NHS staff attending HSSIB courses frequently shared experiences of coroners expecting an investigation and associated report for all incidents they were holding an inquest for. This created a pressure on organisations to carry out an investigation even if the incident was not an agreed local priority for investigation in their PSIRF patient safety incident response plan. HSSIB’s report on learning from deaths in mental health inpatient services includes the issue of coroners relying on investigation reports for inquests. The HSSIB report points out the difference between the purpose of PSIRF investigations – learning from patient safety incidents – and of coroners’ inquests which aim to determine how a person died.

2.4.27 Interviewees said coroner involvement with an incident can also influence whether statements are requested as part of an investigation. If an inquest is being held, investigators in organisations might ask NHS staff to write a statement for the investigation as an efficiency measure and to avoid duplication of effort by those involved in the incident.

2.4.28 NHS England said that it was carrying out work to understand more about the intersection between PSIRF and the coronial process. In collaboration with NHS Resolution, it is aiming to create greater clarity across patient safety teams and legal teams about the purpose and boundaries of investigations and other learning responses under PSIRF. It pointed out that organisations needed to support coroners to fulfil their role without leaning on the PSIRF learning responses process to do this.

Summary

2.4.29 The lack of central funding for PSIRF implementation may have contributed to the variation in support provided within organisations to implement it.

2.4.30 Greater oversight of PSIRF implementation in organisations is needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.

2.4.31 Investigations involving multiple providers are difficult for a single organisation to co-ordinate.

2.4.32 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.

2.4.33 Coroner’s expectations can influence an organisation’s choice of learning response to an incident.

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:

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

2.5.1 During the interviews held for this report, issues were raised regarding the impact that other learning responses are having on investigation work. This information is included to share the insights gained and to further support the development of this area of PSIRF.

2.5.2 PSIRF guidance promotes a proportionate approach to investigation and allows flexibility in the learning response to patient safety incidents. The learning response toolkit includes other learning response methods including after action reviews and multidisciplinary team reviews. The flexibility of response to patient safety incidents under PSIRF impacts on investigations both in terms of the number undertaken and which incidents are investigated.

2.5.3 Investigation is still required for some incidents (such as ‘never events’ and deaths thought more likely than not to have been caused by problems in care) but PSIRF sets no further rules or thresholds for investigation. The framework states that investigation of an individual incident may only be needed when the contributory factors are not well understood or that a thematic review of past learning responses may be undertaken to inform the development of a safety improvement plan.

2.5.4 Interviewees said that feedback from NHS staff showed they welcomed the flexibility allowed under PSIRF and were using other learning response methods in the toolkit. They described a reduction in the number of investigations undertaken, with other learning responses taking precedence. Interviewees said NHS staff described the change in requirement for investigation as making the workload much more manageable.

The learning and insights in this report were gathered through interviews with 18 individuals from HSSIB’s education and investigation teams. Those interviewed were self-selected based on their experience and knowledge of PSIRF and investigation practice under PSIRF.

Interviews were structured around a question-set developed to gather information about key elements of investigation practice, for example:

• experiences and feedback gained from staff about use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework
• experiences and feedback from staff about use of the system-based tools and guides in the PSIRF toolkit
• experiences and feedback from staff about engagement and involvement of those affected by incidents in investigations.

The interviews were recorded and transcribed. The interview transcripts were analysed by the two interviewers. Each interviewer took responsibility for independently coding a number of the interviews, with the other interviewer providing ‘check and challenge’ on the data selected.

During the analysis process, the predetermined topic areas were refined and new topic areas added to adequately capture all the information provided by interviewees. The topic areas became the sub-headings for the report.