Source · HSSIB Patient Safety Investigation
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
HSSIB’s introductionThis 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.
Published 9 October 2025
Published
NHS staff
Patient safety themes
Patient and family
Indexed content
14 learning prompts
Learning Prompts
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.
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.
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.
Develop an accreditation process to assure the quality of PSIRF training.
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.
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.
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.
Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
Support networks for knowledge sharing and collaboration for investigation staff to help foster learning about investigation practice.
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.
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.
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.
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.
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.