Providing examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF)

We have launched three investigations to provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF).

PSIRF 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. The PSIRF is a contractual requirement under the NHS Standard Contract and as such is mandatory for services provided under that contract, including acute, ambulance, mental health and community healthcare providers.

Our report on investigating under PSIRF identified challenges experienced by investigators in mental health settings in using system-based tools in their investigations. Like our sepsis investigations, we will use the PSIRF system-based tools and guides to demonstrate how these can support learning from incidents in mental health settings. The learning from these investigations will be widely applicable, to all mental health services across England.

HSSIB identified the themes for these investigations by reviewing multiple sources of evidence including:

• national incident reporting systems
• academic literature
• national and international publications
• Prevention of Future Deaths reports (PFDs), issued by coroners
• specific requests from mental health providers for example reports in the context of feedback that they are struggling to understand how PSIRF and system-based tools can be used to investigate mental health related incidents, particularly in relation to self-harm and suicide
• findings from HSSIB’s investigation report ‘Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services’.

We have also engaged with stakeholders including clinicians and national leads to learn more about the issues surrounding mental health investigations under PSIRF and to identify areas where an investigation could focus to help improve patient safety. Evidence from the intelligence gathered suggests that investigations into the following incidents may be the most helpful:

1. An incident involving the suspected suicide of a person in contact with community mental health services.
2. An incident involving a person who self-harms while in inpatient mental health care.
3. An incident involving a person who experiences a physical health problem while in an inpatient mental health care who then requires admission to an acute hospital.

These incidents are those most frequently reported or reflect key health inequalities for people with mental health problems in contact with healthcare services.

The three investigations will focus on the barriers and enablers to providing safe care to mitigate the risk of harm in the different scenarios.

The investigations will be carried out at different NHS mental health trusts across England and will provide exemplars of patient safety incident investigations (PSIIs). Any safety learning proposed will be aimed at the specific NHS trust where the incident occurred.

We will publish each report as it is completed. We expect to publish the first report in spring, the second report in summer, and the third report in Autumn 2026.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. We would particularly like to hear from mental health trusts who have a recent incident involving one of our three investigation areas above. If you would like to speak to us about these investigations before we publish the final reports, please email enquiries@hssib.org.uk.