NHS announces new system for investigating serious incidents

So often in an inquest, the family of the deceased will say that they want to know why their loved one has died and to be assured that lessons have been learnt and that it is less likely that another family will suffer the same pain and distress in the future. To date, the NHS has used the 2015 serious incident process to investigate deaths.

However, it has been announced that, over the next 12 months, the NHS will implement a new system for investigating serious incidents — that system is called the Patient Safety Incident Response Framework (or PSIRF for short), and the aim is to fundamentally shift how the NHS responds to patient safety incidents. 

How will this be implemented?

This tool will be a contractual requirement for services such as NHS Trusts and those providing community healthcare or mental health services. It is not currently being rolled out in primary care, although it can be used by primary care providers and it is likely that the PSIRF will be expanded to include primary care in the future. 

PSRIF is designed on the basis that humans are fallible but that well-designed systems can minimise the risk of human error and the risk of serious patient harm. The focus is on helping healthcare providers to learn and to improve patient safety by putting the needs of people first and focusing on healthcare systems rather than blaming individuals.

It is also intended to be more flexible than the previous system; PSRIF does not prescribe what to investigate and it allows for investigations into any recorded patient safety incidents, rather than only those that are declared to be “serious”.

The stated aim is to support organisations to deal with incidents in a way that maximises learning and patient safety improvement driven by a patient safety incident response plan that is tailored to the locality by taking into account local systems or factors that may have played a part in any incident and achieving a proportionate response.

That flexibility does have some limits as there is specific guidance for deaths in maternity services, and deaths arising in the following situations must be investigated:

• Incidents meeting the “Never Events” criteria;
• Deaths thought to be more likely than not to have been due to problems in care (incidents meeting the “Learning from Deaths” criteria); and
• Deaths of detained patients or where the Mental Capacity Act applies and there is reason to think the death may be linked to problems in care (incidents meeting the “Learning from Deaths Criteria”).

All of these require a locally-led Patient Safety Incident Investigation (PSII) — the key area of risk being those deaths thought to be more likely than not due to problems in care, as that requires an assessment of why the death occurred and a judgement about the cause of death.   

Where learning points are identified in the PSII, a patient safety incident response plan must be prepared. It must be agreed with the ICB or any other commissioning body and the organisation’s Board; it must also be published on the public-facing part of the organisation’s website. The response plan is a living document that can be changed or adapted as required, and should be reviewed every 12–18 months. 

What about the coroner's investigation?

In the event that a death is investigated by a coroner, any PSII report and any action plan will be disclosed to the coroner, and may be disclosed to any other interested persons.

A PSII investigation is likely to assist the coroner, the family and any other interested persons to identify at an early stage the information that will be relevant to any Inquest hearing. The family will have seen that report and it may have answered many of their questions about the death and what has been done to avoid future deaths.

It will also be crucially important in terms of the coroner’s assessment of whether there is a continuing risk of future deaths, and whether to issue a report seeking assurances that any such risk has been dealt with by the organisation as the response plan will have set out the steps already taken to address any learning points arising from the death.