Source · HSSIB Patient Safety Investigation
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
HSSIB’s introductionThese three investigations provide examples of mental health investigations under the Patient Safety Incident Response Framework (PSIRF). PSIRF sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Currently, two of three investigation reports has been published.
Published 30 July 2026
Launched 23 September 2025
Published
Mental health
Hospital care
Patient safety themes
Indexed content
4 areas of improvement
Areas of Improvement
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.