Investigating under the Patient Safety Incident Response Framework (PSIRF): Patient Safety Learning’s response to HSSIB investigation

Summary

On the 9 October 2025, the Health Services Safety Investigations Body (HSSIB) published a new report looking at the implementation of the Patient Safety Incident Response Framework (PSIRF). This investigation draws on learning and insights from HSSIB’s education and investigation teams. In this article, Patient Safety Learning sets out its reflections on the report’s findings and recommendations.

Content

HSSIB investigates patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care.

From Autumn 2023, NHS organisations in England began to change the way they responded to and investigated patient safety incidents, moving to a new approach called PSIRF.[1] HSSIB’s latest investigation report looks at the implementation of PSIRF.[2]

PSIRF represents a significant shift in the way the NHS responds to patient safety incidents and is intended to be a major step towards establishing a systems approach to patient safety, maximising learning and improvement. A systems approach is one that focuses on understanding how different parts of the healthcare system interact, rather than placing blame on individuals when things go wrong.

PSIRF seeks to support a patient safety incident response system that integrates these four key aims:

1. Compassionate engagement and involvement of those affected by patient safety incidents.
2. Application of a range of system-based approaches to learning from patient safety incidents.
3. Considered and proportionate responses to patient safety incidents.
4. Supportive oversight focused on strengthening response system functioning and improvement.

Patient Safety Learning welcomes HSSIB undertaking this investigation. We contributed to this during its consultation stage and, in this article, we set out our reflections on its findings.

Applying PSIRF tools and guidance

The implementation of PSIRF is a complex innovation in the NHS’s approach to patient safety incident review and investigation. Its success depends, to a large part, on having the right organisational resources, commitment and support to deliver this.

HSSIB’s report says that the staff they interviewed for this investigation showed significant enthusiasm for employing the systems-based investigation approaches that PSIRF recommends. However, they note how those working in patient safety teams have also expressed concerns about the availability of training and support to implement these in practice. It states:

“Interviewees said that there was limited understanding and expertise among staff in applying system-based tools. Interviewees from HSSIB’s education team said most NHS staff attending courses had had no previous training, or any opportunity to practise applying the tools with a mentor with existing expertise to support them as they developed their skills. The comments received during interviews indicated that without these elements in place, it was unrealistic to expect NHS staff to use the tools. This means that the capacity for the tools to drive improvements is limited and their potential is only likely to be fully realised in organisations where the necessary support is in place”

We have heard similar reflections in the Patient Safety Management Network meeting. This is a peer network, open to everyone working in patient safety in the UK, which we host on our patient safety platform the hub.

The availability of training and support in the application of system-based tools recommended by PSIRF remains quite limited outside courses offered by organisations such as HSSIB. While there is some national support, such as specific webinars and events, much of the implementation of PSIRF is left to individual organisations.

There are other sources of external training support available, which can often provide an outline of the basics of PSIRF and its requirements. However, feedback we have received from our networks suggests this support is somewhat limited, not extending to detailed ‘how to’ resources for the implementation of Patient Safety Incident Investigations (PSIIs) or local learning responses.

At Patient Safety Learning, we have sought to provide support directly recently through a pilot Patient Safety Symposium. Organised with the Patient Safety Management Network and the Patient Safety Education Network, this event focused on the application of two specific PSIRF tools, the Systems Engineering Initiative for Patient Safety (SEIPS) and AcciMaps. 

Opportunities for improvement

HSSIB’s report sets out a number of suggestions to help further develop patient safety incident investigation under PSIRF. While these are broadly to be welcomed, below are several reflections that may be of value in identifying what further action is needed:

• HSSIB recommend a review and refresh of the NHS England Patient safety learning response toolkit. We agree that an update of this, with more multimedia resources aimed at making it more user friendly, would be welcome. However, if staff continue to lack access to appropriate training and support to use these tools, this update will ultimately only have a limited impact.
• We welcome the recommendation to publish more examples of PSIIs, not just for improving the process of investigations but to share the outcomes. This can help us to understand the causal and contributory factors of avoidable harm and the action needed to address it. This knowledge should not just be retained by the investigating organisation but should be disseminated for wider learning and action.
• We also reference the above issue in our response to Dr Penny Dash’s Review of the patient safety across health and care landscape in England.[3] In this, we highlight the lack of structured systematic approaches to learning and solution development as a significant gap in the current patient safety landscape in England.
• We agree in principle with the suggestion of providing access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance. However, if this ambition is to be realised, it is our view that this needs to be directed to a specific organisation. Our concern would be without this clarity and ownership; it is unlikely that this will be actioned.
• We welcome HSSIB promoting the potential role of networks for knowledge sharing and collaboration for investigation staff. This is something Patient Safety Learning actively contributes to through our charitable support of the Patient Safety Management Network and Patient Safety Education Network, hosted on the hub.

Engaging and involving patients, carers and families

As noted in the introduction, one of the four key aims of PSIRF is compassionate engagement and involvement of those affected by patient safety incidents. HSSIB’s report advises that while they have generally found this aim is welcomed by NHS staff, how this is done in practice is “variable and dependent on the organisational resources and support in place”.

The report highlights that significant differences can be observed in organisational approaches to this, citing patient safety incident investigations as a specific example. It notes that while in some Trusts these show clear evidence of patient and family involvement, in others this is largely absent or “in the background”.

It also points to inconsistency in capacity and resources. HSSIB state that while some Trusts have significant in-house expertise, such as investigators supported by dedicated family liaison staff, in other organisations the role of family engagement lead was simply an add-on to a person’s main job (often a clinical role).

Our conversations with members of the Patient Safety Management Network echo these findings. While there is support for greater patient and family involvement, there is also significant uncertainty and concern about how to approach and deliver this well. The network’s conversations also reflect another theme touched on by this report, that staff simply do not have the time available to effectively do this. The report states that as a consequence of time pressures, staff often rely on passive engagement methods, such as statements from those involved in incidents, rather than gathering information through interviews and discussions as recommended by PSIRF.

At Patient Safety Learning we believe this is an area that requires action. It seems clear that there is not adequate training or support to deliver patient, carer and family engagement as intended.

Organisational support and leadership

From their interviews in this investigation, HSSIB’s report states that staff:

“… were unanimous that organisational support and informed oversight were fundamental and essential to enable the shift to a system-based approach to investigation with compassionate involvement of those affected.”

However, their findings suggest there is considerable variation as to whether staff working with PSIRF saw this as being in place at their organisation. In some cases, they noted significant investment in setting up multidisciplinary teams and bringing in human factors and ergonomics expertise to the organisation. However, others suggested there had been little investment in their organisations, with staff finding they had limited time, training, experience or expertise in system-based investigation or how to meet PSIRF expectations.

The report also talks about the important influence that Boards and senior leaders have on the investigation approach and practice within an organisation. We would concur with this sentiment but would note that, in our experience, many Trusts find themselves not ready for systems thinking or do not understand what this means for them. Some Trusts are not financially able to reach the recommendations this may result in and therefore settle for a less optimum solution.

This inconsistency of approach can lead to significantly variability in how organisations learn and apply that learning to reduce avoidable harm. In turn, this will not address or could create inequity for patients.

Role of Integrated Care Boards

HSSIB also consider in their report the role Integrated Care Boards (ICBs) play in overseeing the implementation of PSIRF. The feedback they highlight paints a quite negative picture of this:

“Interviewees said there appeared to be a lack of oversight of PSIRF implementation, particularly in terms of knowing whether and how system-based investigation and engagement is being supported appropriately in organisations. Interviewees queried who was best placed to do the oversight needed and what exactly the expectation would be. NHS staff feedback, particularly from interviewees involved with Patient Safety Specialist training, was that external oversight from integrated care boards was 'patchy'.”

We would agree with this assessment. At Patient Safety Learning we have previously made the case in our report, The elephant in the room: Patient safety and Integrated Care Systems,[4]for the role that Integrated Care Systems and ICBs can play in improving patient safety.  However, there remain significant questions about how effective ICB oversight is of PSIRF and, particularly now, whether they even have the capacity to do this when they have been instructed to cut their running and programme costs by 50% by December 2025.[5]

The report also talks about the role envisaged for ICBs in coordinating cross-organisational incident investigations, as suggested by PSIRF guidance. It states that:

 “PSIRF guidance on oversight and patient safety incident response standards state that integrated care boards should provide the necessary support to coordinate these investigations. Interviewees said that NHS staff reported that in reality this support was often not offered or possible.”

As well as the capacity and funding constraints noted above, a report from HSSIB earlier this year highlighted the numerous challenges ICBs face in co-ordinating and supporting investigations in line with national expectations.[6]

You can read our response to this here.[7] We believe that ICBs need to develop an integrated and coordinated approach to safety, reflecting patient care pathways across systems and ensuring consistency and collaboration.

HSSIB’s report suggests the following opportunity for improvement in this area:

“Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.”

While we understand the rationale for this suggestion, we think in practice it is hard currently to see an outcome from this that would rectify the problems highlighted above. HSSIB note in their report that NHS England has commissioned the Health Innovation Network South London to look at oversight by ICBs. At Patient Safety Learning we believe that without additional capacity and funding, it is hard to imagine what recommendations will flow from this that enable ICBs in practice to deliver effective oversight of PSIRF alongside support for cross-organisational investigations.

Concluding comments

For PSIRF to successfully meet its ambition of creating a fundamental shift towards learning and improvement in patient safety investigations, organisations need to implement this as part of a wider move towards a safe healthcare system. As emphasised in our recent response to the 10 Year Health Plan for England, we think this necessitates adopting a broader safety management system approach to healthcare.[8] This must be coupled with structured systematic approaches to learning about avoidable harm that leads to solution development and improvement action in the NHS.

As HSSIB’s latest report highlights, although PSIRF has now been rolled out across the NHS in England its implementation is far from complete. The findings of their investigation suggest there are significant variations in approach between Trusts, a theme also reflected in our report earlier this year looking in detail at Patient Safety Incident Response Plans.[9]

As noted in the report, this is also partly a reflection of the way in which PSIRF has been a national initiative but with heavy emphasis on local implementation:

“PSIRF was introduced without central financial support for organisations to implement it. Interviewees said the consequences of this are reflected in the differing priority and allocation of resources for PSIRF. They emphasised the imperative for dedicated resource for investigation and engagement work and said that without central funding to enable organisations to meet the expectations set in the PSIRF patient safety incident response standards variation was inevitable, particularly given the financial pressures and competing priorities organisations faced.”

Although this investigation has focused on how patient safety responses and investigations take place under PSIRF, the bigger question is how this variation in approaches between Trusts has impacted on patient safety, which currently remains unquantified and unanswered. Ultimately this initiative must be judged on its implementation and effectiveness in reducing avoidable harm.

References

1. NHS England. Patient Safety Incident Response Framework. Last accessed 6 October 2025.
2. HSSIB. Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development. 10 October 2025.
3. Patient Safety Learning. Review of patient safety across the health and care landscape: Patient Safety Learning’s response, 16 July 2025.
4. Patient Safety Learning. The elephant in the room: Patient safety and Integrated Care Systems, 11 July 2023.
5. Health Service Journal. ICBs ordered to cut costs by 50%. 12 March 2025.
6. HSSIB. Safety management systems: accountability across organisational boundaries, 13 February 2025.
7. Patient Safety Learning. Patient safety across organisational boundaries: Patient Safety Learning's response to HSSIB investigation, 13 February 2025.
8. Patient Safety Learning. 10 Year Health Plan: Patient Safety Learning’s response, 14 August 2025.
9. Patient Safety Learning. What do Patient Safety Incident Response Plans tell us about how the NHS is approaching safety investigations? 7 May 2025.