Safety recommendation
HSSIB recommends that the Department of Health and Social Care works with NHS England and other relevant stakeholders, to clarify national expectations for meaningful and restorative learning from patient safety events and deaths in mental health services. This is to ensure effective learning is supported through processes that provide high-quality and transparent investigations within a culture of compassion.
Response:
As the investigation recognises, the Patient Safety Incident Response Framework (PSIRF) is a significant and welcome improvement in how the NHS responds to patient safety incidents. It prioritises compassionate engagement of those affected by incidents; the use of systems-based approaches to learning; an emphasis on proportionality that balances the need to invest in understanding what happened with the need to effectively and sustainably reduce risks; and the importance of effective and supportive oversight.
The PSIRF was published in the summer of 2022 and became mandatory for healthcare provided under the NHS Standard Contract from April 2024. NHS England has emphasised that implementation of PSIRF is not a ‘once and done’ task, but requires ongoing cycles of planning, implementation, review and improvement. NHS England are confident that as PSIRF is being embedded, the four principles that underpin PSIRF are being realised.
It is important that we learn from the implementation of the PSIRF. This is why NHS England committed to review and revise the supporting guidance that underpins PSIRF as implementation generated further insight. As such, NHS England has prioritised review and revision of the ‘’Engaging and involving patients, families and staff following a patient safety incident’’ guide in the first instance. Working with a group of patients, families, NHS leads and staff and academic experts, the guide is being revised to take on board insight from the initial phase of PSIRF implementation and also the findings from the ‘Learn Together’ research led by the Yorkshire and Humber Patient Safety Research Collaboration.
The revision to the guide includes providing further information on what is meant by meaningful and effective engagement and involvement in the response to patient safety events, including in mental health services (the guide is not specific to any one healthcare sector). It emphasises the importance of high quality and transparent investigations, and other learning response methods, conducted with a specific focus on compassion and working with affected patients, staff and families. NHS England are confident the results of this work will fulfil this recommendation from HSSIB’s report.
The Government’s 10-Year Health Plan also sets out important and ambitious reforms to improve the quality and safety of health services. As part of these reforms, a revitalised National Quality Board (NQB) will bring together senior clinical and managerial leaders from the NHS and regulatory bodies, along with patients and patient representatives to oversee quality measurement, transparency, improvement and innovation in the NHS and independent sector.
We will create a new National Director of Patient Experience to bring patient voice ‘in house’, overseeing the collection of more informed feedback from patients and carers, and making it publicly available. As recommended in Dr Penny Dash’s Review of patient safety across the health and care landscape, this Director will consider formal support for those who have, or believe they have, suffered unsafe care.
We will also significantly improve the complaints process within all NHS commissioners and providers, by improving response times to patient safety incidents and complaints by setting clear standards for both the timeliness and the quality of responses to complaints. We will also expect these to be handled within patient experience and patient complaints teams, not via PALS or external advocacy services to ensure a focus on listening, learning and improvement.
Actions planned to deliver safety recommendation:
- NHS England will review and revise the supporting guidance that underpins PSIRF considering insights generated from its initial phase implementation, by Summer 2026. Additional comments: The revised guide and associated documents have been drafted and are now being considered by NHS England editorial team to determine how best to communicate the information that has been developed. Publication/communication plans will be set out in due course.
- A revitalised National Quality Board (NQB) will bring together senior clinical and managerial leaders from the NHS and regulatory bodies, along with patients and patient representatives to oversee quality measurement, transparency and improvement.
- We will create a new National Director of Patient Experience to bring patient voice ‘in house’.
- We will significantly improve the complaints process within all NHS commissioners and providers to set clear standards for both the timeliness and the quality of responses to complaints.
Response received on 26 August 2025.
HSSIB comment: Further updates from DHSC regarding additional detail will be published when available.