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A Practical Guide to Implementing and Embedding the Patient Safety Incident Response Framework (PSIRF)

News and updates on today's conference looking at the practicalities of implementing and using PSIRF.

Patient Experience at the Heart of Patient Safety Investigation

• enabling patient partnership for improvement

• training and supporting frontline staff to work with patient partners

• the role of patients in driving patient safety improvement

• how excellent engagement can produce better results for patients and Trust during investigation of patient safety incidents

 Carolyn Cleveland


Carolyn Cleveland

Director, C&C Empathy Training Ltd

Carolyn, has a background in psychology and counselling, specialising in loss, fear and vulnerability, and conceived C&C Empathy Training from her study and personal experiences of adversity within life, trauma, healthcare incidents, and vulnerability. 

Carolyn talked through her personal experience of loss. Carolyn said "Excellent engagement can produce better results" "Time and again, conflict gets exacerbated because organisations avoid and fear having difficult conversations".

Carolyn went on to ask "What does it feel like when someone is really interested in what you have to say?" "Feeling understood, engaged and empowered as well as more positive and confident compared to how you feel when someone is not interested in what you are saying which can leave you feeling paranoid, angry, frustrated and isolated"

Carolyn brought her presentation to a close by saying "Remember, people will hear your words but feel your attitude"


EXTENDED SESSION: Mortality Governance & Learning from Deaths

• PSIRF and the national framework for Identifying, Reporting, Investigating and Learning from Deaths

• the national context - Learning From Deaths and the introduction of Medical Examiners

• developing Mortality Governance locally

• serious incidents, learning from deaths, and Covid-19

• sharing information about deaths between providers: challenges and information governance


Dr Dee Traue


Dr Dee Traue


Medical Examiner, Royal Free London NHS Foundation Trust

I have been a Medical Examiner at the Royal Free London NHS Trust since 2020 and am leading on the roll out of the ME service to include community deaths in the London Borough of Barnet.

Dee said "Mortality governance is the responsibility of all clinicians" "We need to work together and use the PSIRF, this can improve patient care and safety and provide better support for the bereaved".


Engaging and Involving Patients and Families Following a Patient Safety Incident

• how can we engage, support and involve families following a death?

• ensuring adherence to the Duty of Candour

• working with families to understand the full circumstances and answer questions

• the new guide for engaging and involving patients and families following a patient safety incident


Mr Julian Hendy

Mr Julian Hendy

Co-Founder & Member, Hundred Families, Making Families Count

Julian Hendy is an award-winning documentary filmmaker and investigative journalist. He is the founder of the Hundred Families charity, which supports and advocates for families across the UK bereaved by homicides by people with mental illness. 

Julian said "I think people in the NHS struggle to say sorry, I think they believe it will make them look responsible" he continued "Saying sorry is always the right thing to do, it is not an admission of legal liability, its the first step to learning from what happened and preventing it from recurring".

Julian closed his session by saying "Its important to learn from serious incidents and deaths, so loved ones know the death of their loved one had some meaning".   

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Fri, 7 Jun 2024
15Hatfields, London OR Virtual, Online
Patient Safety in Hospices - In-Person Conference
Fri, 7 Jun 2024
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Root Cause Analysis: 1 Day Masterclass
Choice of Dates
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Investigation and Learning From Deaths
Fri, 14 Jun 2024
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After Action Review Masterclass
Fri, 14 Jun 2024
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NHS Complaints Summit
Thu, 11 Jul 2024
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Complaints Resolution & Mediation
Tue, 17 Sep 2024
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Legal Issues and Liabilities for ICBs
Wed, 2 Oct 2024
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