Newsletter guidance for healthcare providers on PSIRF and inquests (9 February 2026)

Summary

NHS England recently met with the Chief Coroner to explore how the Patient Safety Incident Response Framework (PSIRF) and the coronial process can work more effectively together. There is currently a critical challenge with the two processes because they serve fundamentally different purposes.

PSIRF supports organisational learning and deliberately avoids apportioning blame or identifying cause of death, whilst coroners must answer four statutory questions, including how someone came by their death. 

A newsletter has been published following the meeting, confirming that coroners should no longer expect or require Root Cause Analysis (RCA) reports in place of PSIRF learning responses, as this is no longer the nationally endorsed approach. Evidence gathering for PSIRF and inquests must remain distinct, with causation potentially needing to be established through other means.

This article from law firm Browne Jacobson summarises the new guidance.

Content

In their joint newsletter, both NHS England and the Chief Coroner agreed that evidence gathering for a PSIRF learning response and for an inquest must remain distinct so that each achieves its intended aim. This means coroners may need causation to be established through other means and should no longer expect or require an RCA in place of a learning response, as this is no longer the nationally endorsed approach.

PSIRF outputs, including the rationale for the chosen response and any improvement actions, can provide valuable context about wider circumstances and system changes. Coroners may continue to use learning response outputs as supplementary information when available; however, these should not be relied upon as the primary or sole evidence for an inquest.

Takeaways for NHS trusts and other healthcare providers:

1. Plan for separate causation evidence for the inquest.
2. Establish early coordination between legal and patient safety teams.
3. Use PSIRF outputs strategically.
4. Maintain the integrity of both processes.
5. Challenge coroners requesting RCA reports.