Introduction
The Patient Safety Incident Response Framework (‘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.
PSIRF replaces the Serious Incident (SI) Framework and removes the ‘serious incident’ classification and threshold for it. It embeds patient safety incident responses within a wider system of learning and improvement and prompts a significant cultural shift towards systematic patient safety management.
PSIRF will change the way in which investigations are undertaken for the NHS and consequently the types of investigation reports that are disclosed to the Coroner’s Court will not be in the same format as the traditional SI report.
Below are our top tips for PSIRF and its associated reports in the context of Inquests:-
Top tips
- Patient safety incident investigation (PSII) reports will look different to SI reports (new template, new methods etc).
- A PSII offers an in-depth review of a single patient safety incident or cluster of incidents to understand what happened and how.
- Not all deaths reviewed by a coroner will receive a full PSII.
- Learning response leads within the NHS should not be expected to make judgements about the cause of death within patient safety learning responses (including PSIIs).
- If a PSII has been undertaken in relation to a death which will be reviewed by the coroner, the coroner will receive the investigation report.
- If a different learning response has been undertaken, the output from that response will be shared with the coroner (some early adopters to PSIRF have agreed reporting templates/methods).
- Organisation-wide engagement with PSIRF is key to robust dissemination of learning.
- Compassionate engagement and involvement of those affected by patient safety incidents (e.g., families/staff etc.) will be expected to be undertaken.
- There should be a considered and proportionate response to patient safety incidents (i.e., with flexibility).
- Where there is no specific report generated by the healthcare provider, they will undertake necessary work to respond to the coroner’s questions (and can consider/reconsider if an investigation or other learning response method would be beneficial).
- The remit of learning response methods is focused on system learning and improvement (and do not cover judgements about cause of death).
- The collection of statements is not required for any learning response method (i.e. for a PSII). A system-based method (using interviews, observations, cognitive walk-throughs etc) is used for information gathering.
Witness statements will still likely be required for an Inquest outside of the PSII process, and robust processes for the timely collation of inquest statements should be in incorporated into the healthcare provider’s processes.
Analysis
While the implementation of PSIRF will change the NHS’s approach to the investigation of patient safety incidents, there will be no real change to the Inquest process, in terms of scope, disclosure, pre-inquest reviews etc.
The coroner is still likely to require a witness to give evidence regarding a PSII report and the learning that has been undertaken by the organisation at the Inquest, in order to address whether a Prevention of Future Deaths (PFDs) report is required, however the format and content of the report is likely to change the manner in which that information is presented. The focus of the investigation will have a more holistic approach which will have engaged a wide number of stakeholders.
If you have any questions about this article or PSIRF and Inquests generally, please do not hesitate to contact David Reddington, Legal Director or Rebecca Sharrock, Legal Director.
For further information, please contact:
David Reddington, Hill Dickinson
david.reddington@hilldickinson.com
