The impact of the Patient Safety Incident Response Framework (PSIRF) on preparing for inquests: Navigating the evidential gap (7 May 2026)

Summary

The Patient Safety Incident Response Framework (PSIRF) replaced the Serious Incident Framework (SIF) and became the mandatory patient safety incident response framework for services provided under the NHS Standard Contract in England in Autumn 2023.

With a move away from Root Cause Analysis (RCA) towards a systems-based approach, PSIRF is designed to enable timely and proportionate responses to patient safety incidents, using varied evidence-based methods to generate impactful learning, whilst also fostering openness and a culture of continuous improvement. 

This article from Browne Jacobson, a law firm, reviews nine published Prevention of Future Death (PFD) reports referencing PSIRF, identifies the key themes arising and considers their practical implications for healthcare providers preparing for inquests.

Content

‘PSIRF’ themes from PFD reports:

1. Inadequate incident reporting.
2. Failure to appropriately ‘investigate’.
3. Poor quality of learning response/investigation.
4. Shortcomings in record-keeping and disclosure of documentation for inquests.
5. Lack of evidence of organisational learning.