How PSIRF changed NHS incident investigation, and the skills it now demands
When something goes wrong in healthcare, the consequences for patients, families and staff can be severe. How the organisation responds decides what is learned and what happens next. A well-run patient safety incident investigation can prevent the same harm happening again. A poorly run one can leave families without answers and staff feeling blamed.
The framework for that work changed significantly in England. The skills it depends on did not.
From the Serious Incident Framework to PSIRF
For years, NHS organisations in England investigated serious incidents under the Serious Incident Framework. In 2019, NHS England announced it would be replaced by the Patient Safety Incident Response Framework, known as PSIRF. The new framework was published in 2022, and NHS providers moved over to it by autumn 2023.
The change was driven by concerns that the old approach focused too heavily on meeting deadlines and classifying incidents, and too little on learning. Investigations were often seen as a process to complete rather than an opportunity to improve.
What PSIRF changed
Under PSIRF, responses are proportionate. Organisations decide which incidents to investigate based on the potential for learning, rather than investigating every incident that meets a fixed threshold. An investigation can follow any patient safety incident, not only one classed as serious.
The focus has moved to systems. Rather than looking for an individual to blame, investigators examine how the wider system allowed the incident to happen. Patients, families and staff are to be engaged and involved with compassion throughout, and oversight is intended to support improvement rather than simply check compliance.
Why investigation skills matter more under PSIRF
PSIRF gives organisations more discretion, which puts more weight on the people running each patient safety incident investigation. Fewer, deeper investigations mean each one has to be done well.
The investigator needs to plan the response and agree its scope, secure records, equipment and other evidence early, and interview staff and witnesses fairly and accurately. They need to understand the human factors that contributed, such as workload, fatigue, communication and design, and analyse how the wider system allowed the incident to happen. At the same time, they must support colleagues who may be distressed, keep patients and families properly informed, and reach findings that are well evidenced, with recommendations that can be acted on.
These are investigation skills. They are the same disciplines a detective uses in a criminal case: securing evidence, interviewing well, keeping an open mind and following the facts. They are simply adapted for a healthcare setting, where the purpose is learning rather than prosecution.
The challenges investigators face
Healthcare managers leading an investigation often face the same difficulties. They may be interviewing colleagues they work with every day, who are anxious about the outcome. They have to separate what happened from what people believe happened, and avoid hindsight bias, judging decisions by outcomes that were not known at the time.
They also have to write reports that are clear to families, staff and boards alike, while balancing the investigation with their normal clinical or management role. Training gives investigators a structure for each of these, so they can approach the work with confidence.
Our health investigation training
Our investigation training for healthcare organisations was first developed with medical specialists and a general practitioner, and was accredited by the Royal College of General Practitioners. It is delivered by former senior UK detectives and forms part of our Specialist Investigation Skills programme.
The training covers setting up an investigation and planning the response, human factors, and systems-based analysis tools including root cause analysis. It teaches investigators to interview staff, patients and families, to support staff after a traumatic incident using Trauma Risk Management (TRiM), and to write clear, evidence-based reports and recommendations. It closes with reflective practice and how to turn findings into organisational learning.
Courses are built around your organisation’s own incident types and delivered at your premises or a venue we arrange.
Learning depends on the investigators
PSIRF has given healthcare organisations the freedom to focus on learning. That freedom depends on people who know how to run a thorough, fair and compassionate patient safety incident investigation. Investing in their skills is one of the most direct ways to improve patient safety.
To discuss investigation training for your healthcare organisation, speak to our training team.