"Patient safety is not just a framework—it is a promise". Reflections from a patient safety investigator

Summary

A patient safety investigator reflects on their role in preventing future harm and improving patient outcomes, the responsibility they feel towards patients and their families, and the challenges and frustrations when recommendations they make are not acted upon.

Content

Working as a patient safety investigator is one of the most rewarding and humbling roles I have ever held. Every day, I am reminded that the work we do is not just about policies or processes—it is about people. Behind every reportable incident is a patient who has been harmed, a family who has been affected and a team of staff who are often shaken by what happened.

Our work carries the potential to prevent future harm, improve outcomes and rebuild trust in the healthcare system—but it also carries a heavy responsibility.

When something goes wrong, my role is not only to understand what happened but why. And that 'why' matters deeply, because the answers we uncover can stop another patient from going through the same experience. In this way, every investigation has the potential to be an act of justice—an acknowledgment that harm occurred and a commitment to learn from it.

The Patient Safety Incident Response Framework (PSIRF) has brought renewed focus to this work. PSIRF represents NHS England’s shift away from a reactive, blame-oriented model towards one that is learning-centred and compassionate.[1]

PSIRF recognises that most incidents are not the result of individual negligence but of system vulnerabilities—and it empowers organisations to address those vulnerabilities meaningfully.

I have been fortunate to receive comprehensive training from the Health Services Safety Investigations Body (HSSIB). Their programmes have given me the skills to use a range of approaches, from After Action Reviews (AARs) to thematic analysis, and to apply systems thinking to complex events.[2] This training has changed how I view incidents: not as isolated failures, but as opportunities to deeply understand the conditions that led to harm and to co-create solutions that reduce future risk.

However, successful adoption of PSIRF relies on more than trained investigators — it requires organisational readiness. A culture of psychological safety, leadership buy-in, adequate resourcing and strong governance structures are essential for PSIRF to succeed. Without these foundations, even the most robust investigations risk being seen as tick-box exercises rather than vehicles for genuine improvement.

One of the most challenging realities of this work is seeing recommendations not acted upon because they are seen as “too hard.” Sometimes, our findings point to solutions that require fundamental service redesign, investment in staffing or collaboration with external agencies—changes that can feel daunting for stretched organisations. These recommendations often stall, delayed by financial pressures, operational priorities or uncertainty about feasibility.

This creates a significant risk: when actions are not taken, the same problems can recur, leaving the organisation vulnerable to external scrutiny—from regulators, commissioners or even coroners during inquests. In these settings, we are often asked to demonstrate what has changed since a previous event. If the answer is “very little,” it not only undermines trust with families but can also damage the organisation’s reputation and lead to regulatory consequences.[3]

From a patient’s perspective, this is more than a missed opportunity—it can feel like a betrayal. For them, the investigation process is not just procedural; it is emotional. It is their chance to be heard, to make sense of what happened and to know that their experience will help protect others.

When change does not follow, patients and families may feel that their suffering has been acknowledged but not honoured.

I know that PSIRF represents a long-term cultural shift and that meaningful change takes time. But inaction cannot become the norm. Each recommendation that goes unimplemented keeps the door open to repeat harm. Conversely, each recommendation that is implemented—however small—is a tangible sign that learning has been turned into action.

Patient safety is not just a framework—it is a promise. A promise to patients and families that when something goes wrong, we will listen, we will learn and we will act. Building organisational readiness, creating mechanisms for accountability and ensuring that "hard" recommendations are not quietly abandoned are essential if we are to fulfil that promise and deliver the meaningful, sustained improvement that patients deserve.

References

1. NHS England. Patient Safety Incident Response Framework (PSIRF), 2022. Accessed 10 September 2025.
2. Dekker S. Drift into Failure: From Hunting Broken Components to Understanding Complex Systems. Farnham: Ashgate Publishing, 2011.
3. Care Quality Commission. How CQC interacts with Coroners, 27 August 2024. Accessed: 10 September 2025.

Further reading on the hub

Read all our blogs in our Florence in the Machine series — an area for anonymous health and care staff to blog about the state of the health service as they experience it on a daily basis.

If you work in health or social care and would like to share your experience on the hub, you can email [email protected].

About the Author

The author of this blog wishes to remain anonymous.