Source · HSSIB Patient Safety Investigation
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Published 23 April 2026
Launched 23 September 2025
Published
Mental health
Hospital care
Patient safety themes
These 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, one of three investigation reports has been published.
Summary
4 areas of improvement
Areas of Improvement
Area 1
Area
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area 2
Area
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Area 3
Area
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.
Area 4
Area
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.