Trusts are beginning to run parallel safety investigations because a compulsory new national process does not meet the demands of coroners, HSJ has learned.
One provider said it had already established a separate process for deaths likely to result in an inquest, while others confirmed they were reviewing how they carry out investigations.
National officials admitted separate investigations might be required.
It follows the rollout in recent years of NHS England’s new “patient safety incident response framework” (PSIRF) for all NHS trusts, as well as other providers on the NHS standard contract.
It is meant to be a more “proportionate” process than the previous “serious incident framework”, with a focus on learning and engaging with those affected, rather than attributing blame. One consequence is that fewer incidents – including some deaths – are likely to receive a full investigation.
HSJ has uncovered seven cases – covering nine people – where coroners have issued Prevention of Future Deaths (PFD) reports which raised concerns that the PSIRF is producing inadequate reports or there had been no safety investigation at all.
Barking, Havering and Redbridge University Hospitals Trust has reverted to using root cause analysis as a parallel process for all cases that may be subject to a coroner inquest. This was required “to ensure the coroner received the necessary information, while maintaining the integrity of the PSIRF investigation”, the trust’s board heard last month. Chief medical officer Andrew Deaner said: “Nationally coroners were finding some issues with the PSIRF process.”
A Department of Health and Social Care spokesperson said: “Under the [PSIRF], all deaths thought likely to be down to problems in care must be subject to a patient safety incident investigation.” However, they added: “It is vital that NHS trusts continue to engage with coroners and work with them to ensure that coroners get the information they need.”
NHS England has also said it is aware some coroners had raised concerns, although it consulted the chief coroners’ office in developing the PSIRF. It acknowledged the methodology may differ from a coroner’s remit, and said NHS organisations could use other methods in addition.
The judiciary office and the Coroners’ Society did not want to comment.
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Source: HSJ, 29 July 2025
