Managing Coroner’s expectations in the PSIRF era

A hospital trust has recently been criticised for its “poor” and “defensive” investigations into three deaths. The Coroner’s PFD report (Lorraine Parker (1): Prevention of Future Deaths Report - Courts and Tribunals Judiciary) included criticisms that the trust did not carry out a “detailed [Patient Safety Incident Response Framework] report” (which supports responses to patient safety incidents) into any of the deaths; that its Structured Judgement Reviews (which investigate care failings following a patient death) were “at best, poor” and “at worst, defensive”. The Coroner warned the trust that its overall death investigation process “is not working well”.  

An HSJ article on 29 July 2025 refers to seven cases – covering nine people – where Coroners have issued PFDs raising concerns about inadequate PSIRFs (whether because the investigation lead is not fully skilled to do one, or because the Trust is not utilising the various ‘tools’ that PSIRF has for a trust to use in relevant circumstances) or there being no safety investigation at all. It therefore appears that increasing numbers of PFDs are being issued to Trusts around the quality of investigations being undertaken:  

As noted in an HSJ article on 29 July 2025, some Trusts are beginning to run parallel safety investigations using the old SIF because PSIRF does not meet Coroners’ demands but this is duplication, time consuming and costly. 

While the Coroners have criticised Trusts, could there be a deeper issue here around whether Trusts are struggling to get the balance of investigation – or no investigation – right and/or implement adequate PSIIs due to the system’s less rigid/ prescriptive structure? The HSJ refers to DHSC saying all deaths thought likely to be due to problems in care should be investigated through PSIRF. The difficulty is that this requires the Trust to have a suspicion that poor care was involved, and this may not be evident from the internal investigation, especially if it was of poor quality.  

It is not a case of simply moving back to using SIFs as patient safety and quality improvement in healthcare has been steadily moving from “What happened and who got it wrong?” to “Why did this happen — and how can we design our systems to prevent it?”. Trusts are having to balance a complex triangulation of learning with claims and investigations alongside burgeoning guidance and regulation around responsibility for the quality of investigations. 

For years, the Serious Incident Framework (SIF) was the backbone of how the NHS responded to patient safety incidents. Its structure was: define the harm, investigate the timeline, assign a root cause, and generate an action plan. In response to concerns that the SIF was reactive and bureaucratic meaning opportunities to reduce recurrence of harm were missed, in 2022, NHSE and NHSI published the much- awaited Patient Safety Incident Response Framework (PSIRF). In a marked change to the old system, PSIRF set out a broader, more proactive and risk-based, less prescriptive approach with Trusts being able to decide whether incidents qualify for a Patient Safety Incident Investigation (PSII) or whether other alternative proportionate responses may be followed instead, such as  case note review; time mapping; ‘being open’ conversations; after action review; audit. In some cases, it may be decided that ‘do not investigate’ or ‘no response required’ is appropriate. One consequence of PSIRF is that fewer incidents – including some deaths – are likely to receive a full investigation.  

Evidencing learning from investigations is no longer a choice. Sir Rob Behrens, the former Parliamentary and Health Service Ombudsman, stated to the Thirlwall Inquiry that, “time and time again we have seen senior managers and boards are more interested in preserving the reputation of their organisation rather than dealing with patient safety issues.”  As well as reputational damage through inadequacies being highlighted publicly, more responsibilities are being put in place, for example, by the SRA’s new In-House Guidance for in-house legal teams. As we discussed at our In-House Legal Forum, this includes a duty to escalate and report certain concerns and guidance on improving internal investigations. The Government has also recently decided (following a consultation) to regulate NHS managers to ensure they follow professional standards and are held to account to ensure patient safety. Weightmans Partners, Nichola Halpin and Emlyn Williams, analyse this decision here.  

When conducting internal investigations, patient safety teams must be mindful that should the case go to inquest, the Coroner will want dates, times, names, action plans and evidence of progress or change. 

When there is an unexpected death, patient safety teams need to decide how they investigate at the beginning , and to be mindful at an early stage as to whether a case may go to inquest and what a coroner will need, such as a chronology of events, some analysis of what happened and why and that a plan has been put in place/implemented to evidence learning, progress or change. They may also want to discuss with the legal team as we know some trusts have more inquests than others, These steps should help avoid having a parallel investigation, wasting time (PSIRFs main aim is to streamline, and we have seen the same in the NHS 10 plan and the Dash review) or putting witnesses through two ‘investigations’. 

At our In-House Legal Forum, one of our guest speakers, Sarah Mather, Head of Legal at Calderdale and Huddersfield NHS Foundation Trust, demonstrated the practical ways her in-house legal team is assisting with learning after incidents by identifying legal themes and trends to develop focussed learning and education packages; utilising thematic reviews as claims and inquest trends evolve to reduce claims volume and the risk of PFD reports; creating ways to reflect on GIRFT data to try to reduce future claims; liaising with clinical governance staff to discuss case law updates, scorecards and individual legal portfolios; implementing recommendations and learning from panel solicitors; using case management systems; and, perhaps most exciting of all, using predictive analysis to mitigate risks and capitalise on opportunities - using large data sets across patient experience, complaints, incidents and legal to forecast trends.