Closing investigations: The role of national policy in shaping structural, organisational and relational constraints on learning from patient safety incidents (December 2025)

Summary

This study aimed to understand the role of a national patient safety policy, the Serious Incident Framework, on local organisational practices of responding to, investigating, and learning from patient safety incidents in the NHS in England.

Content

Qualitative interviews were conducted with healthcare professionals in six NHS organisations and analysed using inductive thematic analysis and taking a constant comparison approach. Systemic challenges linked to the policy’s prescriptive requirements were identified, including its emphasis on metrics such as incident closure and harm levels, which often obscured meaningful learning and systemic improvement.

The findings highlight the misalignment between the policy’s key aims and principles and its practical implementation, revealing an ‘industry of investigations’ that risked turning the investigative process into a compliance-oriented ‘tick box exercise’. Furthermore, the overspecification of performance requirements coupled with the underspecification of substantive guidance led to variability in investigative processes, organisational capacity and resources, and investigator training and expertise. The involvement of patients and families affected by safety incidents was found to be inconsistent and often limited, with perceptions of senior managers and frontline staff underlining some tensions in operationalising large patient safety policies.

The analysis considers how the development and implementation of national safety incident policies needs to carefully and intelligently balance the need for adaptive flexibility, clarity of guidance, and specification of organisational resourcing and infrastructure to ensure future national policy can effectively support local practices of learning from safety incidents.