The Health Services Safety Investigations Body (HSSIB) has released it's learning and insights of investiagtion under PSIRF.
The report finds hea
lthcare staff are positive about the impact that PSIRF can have on patient safety, but also reveals that more resource and support is needed to ensure it is implemented consistently across England.
Key Findings include:
The shift to a system-based approach to investigation, with greater involvement of those affected by incidents (patients, families and staff), has been positively received by NHS staff.
Staff value having the flexibility to choose a range of learning responses to patient safety incidents. After action review is the chosen learning response to many incidents that previously would have triggered an investigation.
Using system-based tools, and involving patients and families in investigations, requires particular knowledge and skills which many staff have not had the opportunity to develop.
Organisational support and informed oversight are fundamental and essential conditions to enable the shift to a system-based approach to investigation with meaningful involvement of those affected.
There is variation in the investment organisations have made to implementing PSIRF and its aims, with resulting variation in progress and practice. Greater oversight and support are needed to help ensure consistency in how PSIRF is understood and applied in NHS trusts.
Read more www.hssib.org.uk
"Staff strongly agree with the shift to a system-based approach to investigation and the need to compassionately engage and involve those affected by incidents, seeing this as not only beneficial but the right thing to do. However, the findings also point to the need for a greater focus on implementation and resourcing to ensure PSIRF can reach its full potential. Boards and senior leaders play a critical role in shaping the culture and practice of investigations, their full organisational support is essential to create the conditions needed for PSIRF’s aims to be realised.”
The report calls for NHS England to review and refresh the PSIRF learning response toolkit, and for local and national organisations to provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
Featured Event:
Investigation and Learning From Deaths
Wed, 12 Nov 2025 | Virtual, Online
The conference will update delegates on the National Patient Safety Incident Response Framework (PSIRF) and the implications for patient safety incident investigation and learning from deaths.
