The Patient Safety Incident Response Framework (PSIRF) is the new way that the NHS looks at Patient Safety Incidents. It has replaced the Serious Incident Framework (2015) and represents a significant shift in the way the NHS responds to patient safety incidents.

It supports the development and maintenance of an effective patient safety incident response system PSIRF will lead to more compassionate engagement and involvement for those affected by patient safety incidents and give staff space for reflection. An important factor is to understand how incidents happen. This allows us to learn and improve, in turn creating a safer care system for patients.. The four key objectives are:

  1. Compassionate engagement and involvement of those affected by patient safety incidents
  2. Application of a range of system-based approached to learning from patient safety incidents
  3. Considered and proportionate responses to patient safety incidents
  4. Supportive oversight focused on strengthening response system functioning and improvement.

CNWL launched PSIRF at the end of November 2023, from this date our Patient Safety Incident Response Plan has been adhered to.

The CNWL PSIRP was co-developed colleagues across the Trust, Carers, Patient and our Patient Safety Partner. We have chosen five priorities to focus on over the next two years, We will continue to review these through quarterly analysis of the Trust’s Safety Profile.

Please find our PSIRP here.

This details the processes that we will follow to investigate patient safety incidents, focussing on systems learning. There are a range of investigation responses that we can use, this includes Patient Safety Incident Investigations and After Action Reviews. In both of these we will involve patients/service users and their families and carers in these investigations.

A key aspect of our PSIRF Policy is engagement. CNWL will gain feedback on an ongoing basis from our patients/ service users, their carers and families and staff to make sure we continue to learn from incidents and the PSIRF approaches, to develop and improve them on an ongoing basis.

If you are a patient, service user, carer or family member and have been involved with a Patient Safety Incident Investigation (PSII) and would like to provide us with feedback on your experience, please contact our Patient Safety Incident Investigation team or please follow this link to our Patient outcome survey.

As part of our requirements under the Duty of Candour policy, where a patient suffers moderate harm or greater, we have an obligation to provide a verbal apology and to follow this up with a written apology – providing details of any potential investigation that may be ongoing.

Click here to read more about out PSIRF plan.

The Duty of Candour policy has been refreshed to reflect the Patient Safety Incident Response Framework (PSIRF), focusing on how compassionate engagement and Duty of Candour work hand in hand to support patients and their families following a Patient Safety Incident (PSI).

The new framework provides a greater emphasis on good quality and meaningful engagement with patients and staff. Feedback is essential so that we can keep learning and improving our processes.

With this in mind we’ve also updated our incident recording system to capture further information regarding our new learning responses, and to consider the support we are providing to staff and patients involved in PSIs.

We've created a series of films about PSIRF below