Source · HSSIB Patient Safety Investigation
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Published 9 October 2025
Published
NHS staff
Patient safety themes
Patient and family
This report shares our learning about patient safety incident investigation under the Patient Safety Incident Response Framework (PSIRF). It's intended for national and local organisations and policymakers to help inform future work to support staff in system-based investigation across the NHS in England.
Summary
14 learning prompts
Learning Prompts
Prompt 1
Learning prompt
Review and refresh the PSIRF learning response toolkit, to include the use of multimedia guides, to help make the tools and guides easier for investigators to use.
Prompt 2
Learning prompt
Publish examples of patient safety incident investigations which include the PSIRF system-based tools and guides used to help investigators understand their application. Examples may be particularly beneficial in sectors that may have struggled with, or be new to, implementing PSIRF.
Prompt 3
Learning prompt
Support PSIRF education and training to focus on the practical application of PSIRF tools, taught by people with demonstrable expertise in applying a system-based approach and tools in investigations.
Prompt 4
Learning prompt
Develop an accreditation process to assure the quality of PSIRF training.
Prompt 5
Learning prompt
Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.
Prompt 6
Learning prompt
Provide greater clarity on the role of PSIRF investigations and other learning responses in the coronial process to help support organisations subject to a coroner’s inquest.
Prompt 7
Learning prompt
Provide guidance on the practical steps to take to decide on the most appropriate learning response to an incident, to help organisations adopt a robust, standard approach to their decision making.
Prompt 8
Learning prompt
Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
Prompt 9
Learning prompt
Support networks for knowledge sharing and collaboration for investigation staff to help foster learning about investigation practice.
Prompt 10
Learning prompt
Use the patient safety incident response standards and national guidance on engaging and involving those affected to assess practice and identify where additional resource and support is needed.
Prompt 11
Learning prompt
Use the patient safety incident response standards and oversight roles and responsibilities specification to assess organisational support and where further resource is needed for PSIRF implementation.
Prompt 12
Learning prompt
Use the patient safety incident response standards and oversight roles and responsibilities specification in oversight processes to highlight where further support and resource is needed to meet the expectations under PSIRF.
Prompt 13
Learning prompt
Increase access to education and training, focused on the application of system-based tools, and taught by people with demonstrable expertise, to help staff to carry out system-based investigations.
Prompt 14
Learning prompt
Develop training in after action review and thematic analysis which includes a practical component where learners have an opportunity to apply the approach, to help ensure these learning responses are effective.