Reflections After Two Years of the PSIRF

My reflections on the PSIRF two years on – Kate Jury, Managing Partner

With many NHS organisations now marking two years into their Patient Safety Incident Response Framework (PSIRF) journey, I wanted to reflect on the successes, challenges, and sometimes unforeseen consequences of the framework’s implementation.

The PSIRF, introduced nationally in 2022, set a new gold standard for how the NHS responds to patient safety incidents. The framework was designed to move away from a blame culture and towards a more systems-based learning approach, ensuring families were more included in the process of an investigation, reducing repetitive incidents, and trying to impact the ever-increasing burden of litigation upon the NHS.

Now two years on, the Health Services Safety Investigations Body (HSSIB) has published its report on findings from the implementation of PSIRF. Their conclusions, however, outlined a number of both interesting and anticipated outcomes.

Many of their findings chime with some of Niche’s early concerns on areas for potential misalignment of the framework, with areas for improvement highlighted in several key aspects. – read here.

Variation in PSIRF

A notable theme highlighted by the HSSIB report is ‘variation’ surrounding implementation. Within this is variation in funding and resources, support, application, leadership, effectiveness and engagement. Particularly pertinent is the need for more financial support to ensure the best incorporation of the framework; at the moment, it could be bluntly estimated as being a halfway successful implementation.

Tension between needs versus wants

While systems-based learning and avoiding individual blame is the cornerstone approach of PSIRF, this doesn’t always meet the expectations of families or Coronial processes. As we know, Coroner’s Courts will always require a forensic, antecedent investigation report; they are not particularly seeking just culture approaches. The requirements of a Coroner have primacy over an organisation’s own preferred patient safety response. Families too want to know that the truth and facts have been surfaced by an investigation and will unlikely be assured by a thematic review.

There is some inevitability that staff will prefer systems-based approaches which avoid blame, but the focus on the avoidance of blame (as opposed to fair blame) can sometimes leave families feeling cheated of accountability.

How can organisations improve delivery?

Some organisations reported that very little had changed since the introduction of PSIRF and that they were still struggling with enhanced engagement practices, and that as long as they had fulfilled Duty of Candour towards families, then this had sufficed.

How and where organisations can do more for families remains a question which needs more focus. On one hand, there was an appetite for dedicated family mediation support, on the other hand, families felt this sometimes added an additional barrier between them and the ‘system’.

The key to successful delivery of PSIRF approaches is organisations’ ability to deploy the most appropriate and proportionate responses to incidents. Yet, care should be taken not to downgrade responses at the cost of speed and efficiency. Under these current conditions, organisations may find they have less choice than they thought when it comes to meeting the needs of families and Coroners alike.