Proactive governance – the Patient Safety Incident Response Framework

Central to the Patient Safety Incident Response Framework (PSIRF) is the requirement for healthcare organisations to be proactive in how they respond to and learn from patient safety incidents.

Here we consider the implications of PSIRF on healthcare organisations’ legal and governance teams. In particular, considering practical steps that may be adopted, as an example, in the context of preparing for an inquest.

A meaningful approach to PSIRF laying the groundwork for inquest preparation, a culture of continuous improvement and informing governance for the purposes of policy and strategy.

Evidencing and disclosure

The Chief Coroner’s guidance states that evidence collated for inquests “needs to be relevant, reasonable, sufficient and proportionate to the scope of the inquest” (Guidance No.44 - see here).

Under the former Serious Incident Framework (2015), Serious Incident Reports (SI reports) and Root Cause Analysis’ (RCAs) were the key documents that healthcare organisations often disclosed in advance of an inquest, at the request of the Coroner.

The introduction of PSIRF does not alter what a Coroner may request. Whilst the above may not be available, and the quality of the above varied, requests for disclosure of any investigations and requests for comments from treating clinicians will continue.

We have previously summarised the new learning response methods healthcare organisations are invited to use under PSIRF, in place of SI reports and RCAs (see here).

In certain circumstances, organisations will prepare Patient Safety Incident Investigations (PSII). These may be similar to SI Reports and RCAs, but with a systems approach taken. It is envisaged that Coroners may request witness evidence from those who drafted such investigations. Possibly with disclosure of notes from swarm huddles, after-action reviews and any multidisciplinary team meeting notes.

Coroners will also be interested to know what learning has been proposed and whether this has been adopted. Witness statements of treating medical staff are not required under PSIRF’s learning response methods. However, it may well be advisable for organisations to obtain witness statements outside of the patient safety process, for the purposes of inquests or any litigation that may follow.

Practical steps

Continuing to adopting the example of preparing for an inquest, it can be seen that PSIRF does provide an opportunity for those in governance to have early insight, at system level, with a view to better supporting both those called to give evidence and those who are patients of the organisation.

In anticipation of an inquest being called, separate from a simple fact finding exercise, there is scope to gather and retain evidence, for benefit of patients, families, staff and the future of the organisation.

Practical steps to assist organisations with a pro-active approach in adapting to PSIRF in the context of inquests, giving those in governance a reliable overview, include:

1. Involve the Coroner in the planning and implementation of the organisations PSIRF approach, when an inquest is opened.

2. Take an open and positive approach, once the Patient Safety Incident Response Plan (PSIRP) - setting out how the organisation intends to respond - has been finalised, with the Coroner being provided with a copy. This is likely to aid all concerned. In particular, the family. Further, the Coroner will have a better understanding of the changes an organisation is making and the wider context of its patient safety priorities.

3. Develop the skills of those gathering evidence to listen. Part of this being an ability to understand diversity of thought and an ability to show compassion. Having self-awareness and self-control. This being balanced with a focus on the core issues relevant to the individual providing evidence, such as their role, what they did and did not do and what they propose be learnt.

4. Adopt processes and ensure time is set aside for clinicians, and other staff, to contribute and provide comments at an early stage following a patient safety event. Evidence provided nearer to the time of the incident, providing secured in a calm environment and with a clear head, is likely to resonate, when it comes to establishing areas for improvement.

5. Encourage accountability from those taking part. Not a forum for blame, but an opportunity to take responsibility both for actions or inactions of the past and for the future.

6. Ensure open questions are asked, seek clarity on the chronology of events, challenge elements demanding challenge in a supportive manner, and invite reflections since the event, or events, took place.

7. Document effectively the swarm huddles, after-action reviews and other such meetings, having taken a multi-disciplinary approach. Aim being for information not to be lost, either by way of failure to capture or by way of a disproportionate amount of information being gathered, which then confuses and distracts. There should be consistency in the quality of evidence derived from such meetings.

8. Preserve evidence, for example, clinicians’ and staff comments, documents detailing rotas, policies and procedures in place at the time. With ease of access to these documents, and any other documents, for all those required to contribute to the PSIRF approach.

9. Update those who have contributed to developing recommendations and outcomes. Ensuring that those who have provided evidence are valued by way of continued scope for reflection and an open approach.

10. Support all those taking part in the PSIRF process. Evidencing and reflecting on events is difficult for all involved. There are emotional elements to the above dialogue. The benefits to staff retention of a caring and compassionate environment are obvious, with the supportive culture within the organisation, being evident to all.


PSIRF changes what evidence may be gathered and what will be available to both the Coroner and to those in governance in the future.

The onus remains on healthcare organisations to ensure that the evidence that is provided enables a Coroner to address the four statutory questions (who, when, where and how did the deceased come to their death). The healthcare organisation will also want to show to the Coroner that a Prevention of Future Deaths Report is not required. This being a reflection of the pro-active governance that is already in place, which has secured a safer and sustainable approach for the future.

The compassionate and inclusive approach indicated is the key. This should improve relationships both, internally, within the healthcare organisation and, externally, with those effected and those who may be reviewing, such as the Coroner or the Care Quality Commission.

This approach, which we appreciate does require financing and resourcing, links with what matters to so many in governance at present. Ensuring that there is a restorative and just and learning culture in place. An environment at the healthcare organisation where an adverse event, or adverse events, are seen as an opportunity to learn, and to improve patient safety.

Previous work undertaken by Mersey Care NHS Foundation Trust, which pre-dates PSIRF, in 2016, shows how this can be achieved and the benefits that derive from such an environment.

Improved communication, conversation and recording of that evidence, seems to be at the heart of this. PSIRF providing the principles to adopt to secure a consistent and open approach.

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