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 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.

The challenges 

The changes in approach to incident investigations under PSIRF are undoubtedly positive for improving the way in which organisations respond to patient safety incidents and identify system learning. However, it has also introduced new challenges for other, separate, processes which may take place following a patient safety incident, including inquests.

Historically, under the SIF, coroners tended to rely on Serious Incident investigation (SI) reports, which included a detailed chronology of events and RCA. These documents were used as evidence of what had happened and what actions or inactions may have caused or contributed to the death. Now that this information does not routinely form part of a learning response under PSIRF, there is a potential evidential gap for the inquest. However, as recently clarified by the helpful NHS England newsletter on PSIRF and coronial processes, coroners should no longer expect or require RCA reports in place of PSIRF learning responses. Furthermore, and crucially, evidence gathering for PSIRF and inquests must remain distinct, with causation potentially needing to be established through other means. 

In practical terms, this means that healthcare providers preparing for an inquest need to carefully consider what evidence will be needed by a coroner and whether this can be adequately provided from the PSIRF learning responses and outputs or whether supplemental evidence is needed and, if so, how best to present this at an inquest.

This has created a number of challenges, some of which have been highlighted in published Prevention of Future Death (PFD) reports where coroners have identified various concerns about how some organisations have responded to incidents under PSIRF, including concerns about the way in which incidents are identified for investigation and the quality of learning responses/outputs under PSIRF. 

Bridging the evidential gap

As at the date of this article, there have been nine published PFD reports which reference PSIRF, dated between 28 March 2024 and 29 September 2025 (relating to deaths between 16 November 2019 and 13 December 2024). It is of note that one of these relates to a death in 2019, when the SIF was still in place. However, at time of inquest in March 2025, the Coroner was not persuaded improvements in investigation had been made since the implementation of PSIRF.

We have undertaken a thematic review of the nine PFD reports and responses. Whilst recognising there are limitations to this review, including the relatively small number of PFD reports, (four of which were issued against the same Trust by the same Coroner), there are some key themes and useful learning. We discuss the findings below. We have also used the themes and learning to produce a PSIRF Inquest Toolkit to support In-house legal teams preparing for inquest. 

It is our intention that this summary of themes and the PSIRF Inquest Toolkit will be a useful update to the PSIRF Check-list for Heads of Legal which we prepared when PSIRF was first introduced.

‘PSIRF’ themes from PFD reports

1. Inadequate incident reporting 

Incident reporting is an important first step in the identification of incidents to be reviewed under PSIRF, enabling the evaluation of incidents against an organisation’s Patient Safety Incident Response Plan (PSIRP) and the consideration of an appropriate response to an incident, whether that is a Patient Safety Incident Investigation (PSII) or another type of learning response.

In three of the nine PFD reports (albeit all from the same Coroner, relating to the same Trust), there were shortcomings in the incident reporting process, for example a Datix report had not been completed contemporaneously. These shortcomings were deemed to have contributed to subsequent failures in identifying incidents as worthy of investigation under PSIRF.  

Two other cases flag the importance of ensuring the ‘harm’ classification is recorded accurately and consistently to enable learning. 

2. Failure to appropriately ‘investigate’

Whereas, historically, the SIF tended to result in a reactive ‘one size fits all’ response to a patient safety incident, by way of RCA and SI report, PSIRF provides a framework for a strategic and proactive approach to patient safety. 

Under PSIRF, a PSII is just one of a range of learning responses, with alternative responses such as After-Action Review (AAR) and swarm huddles designed to respond more quickly and effectively to appropriate incidents. How an organisation determines the most appropriate way to respond to an incident will vary and be dependent on a number of factors, including the organisation’s patient safety priorities, outlined in its PSIRP. However, in addition to the need for robust incident reporting systems to capture relevant incidents, discussed above, the success of PSIRF also relies on robust and transparent decision-making processes for identifying the need for a PSII.  

Five of the nine PFD reports raised concerns that appropriate ‘investigation’ under PSIRF had not been initiated. This was often as a result of wider governance failures, highlighting the importance of:

• Clearly defined and consistently applied criteria and thresholds to determine when a PSII or alternative learning response is required. 
• A process to ensure that decisions about how to respond to an incident are informed by all relevant sources, including outputs from morbidity and mortality reviews (discussed below), concerns raised by families/carers and the coroner. 
• A system which enables a review of the initial decision, if appropriate – for example, to respond to emerging information or stakeholder concerns.

These cases also highlight the need to ensure that evidence presented to the Coroner at an inquest provides a clear understanding of the PSIRF process, including the rationale and scope of the PSIRF learning response/investigation undertaken. 

In addition to the standard disclosure of statements and copies of learning response outputs/investigation reports, those preparing for an inquest should consider providing an overarching Position Statement to summarise and explain the PSIRF response; the rationale and scope of the PSIRF investigation; the learning and actions arising from the PSIRF investigation; the outcome of reviews undertaken as part of the learning from deaths process; and any additional investigations undertaken as a result of postmortem reports and/or further requests from the coroner.

3. Poor quality of learning response/investigation 

In the cases where a learning response or PSII had been undertaken, concerns were raised about the quality of learning, with some investigations being criticised as inadequate, narrow, or superficial. 

These cases highlight a number of specific issues including:

• The importance of good quality training for investigators using PSIRF principles to ensure quality, compassion and consistency in approach.
• Learning responses/PSIIs need to involve relevant clinicians, both in terms of understanding what happened, how and why, and also when considering workable safety actions and system changes to prevent future harm.
• The importance of transparency, candour and engaging with families throughout the investigation process, ensuring that any concerns raised by the family are acknowledged and responded to in advance of the inquest.

4. Shortcomings in morbidity and mortality (M&M) meeting processes

It is of note that in addition to identifying issues with PSIRF, some of the PFD reports highlighted wider issues about the inter-relationship between PSIRF and other learning from deaths/mortality processes that sit outside of the coronial process. In particular, the need to ensure that:

• M&M meetings are conducted in a timely manner, without delay.
• A system to regularly check the status of pending Structured Judgement Reviews (SJRs)/Patient Safety Reviews so these can be presented to the relevant department at the formal M&M meetings. 
• Learning points and any other salient and notable points are shared with the wider M&M group.
• SJRs are conducted appropriately – in one of the PFD reports the SJRs were described as "at best, poor, and at worst, defensive".
• A clear and accurate record is made of the discussions, including any concerns identified at M&M and clinical governance meetings. 

5. Shortcomings in record-keeping and disclosure of documentation for inquests

In addition to poor clinical record-keeping that directly impeded some of the investigations, three of the PFDs raised concerns about governance record keeping and disclosure of documentation for the inquests. These included concerns about:

• Document version control and audit, with the Coroner referring to ‘chaotic governance arrangements’, and a pattern of rolling disclosure of documents during the inquest. 
• A failure to preserve critical evidence that was known to be important for the inquest.
• Shortcomings in relation to the systems for collating and providing medical and clinical governance records, with routine difficulties obtaining medical records and late production of documents.

6. Lack of evidence of organisational learning

Some of the PFD reports identified systemic failures with governance structures being either structurally weak or culturally resistant to learning from adverse events, highlighting the importance of evidencing organisational learning at an inquest.

By way of example, in one case relating to the death of a patient with a penicillin allergy where no allergy checks had been undertaken, learning was communicated only via informal means (email and a "message of the week"), without being enshrined in any formal Trust policy. Subsequent audit found continued concern about allergy status checking and Trust communications referenced other adverse incidents, suggesting the learning had not been communicated effectively and/or that lessons were not being embedded.

In another case, Trust correspondence sent three months after the inquest indicated an apparent lack of understanding of NHS England’s guidance on what should trigger a patient safety investigation.

Conclusion - what does all this mean in practice?

PSIRF signified a new era for patient safety incident management across the healthcare system in England. Although it is now over three years since implementation, it will continue to take time for organisations to establish the systems and behaviours of an ‘effective and compassionate patient safety reporting, learning and improvement system’ underpinned by openness and transparency, just culture and continuous learning and improvement.

Recently there has been considerable discussion about the impact of PSIRF on the inquest process, with nine published PFD reports highlighting various coronial concerns about how effectively the PSIRF process has been implemented to identify learning and bring about system change to prevent harm. However, a review of those PFD reports highlights the importance of a holistic approach to learning and how shortcomings in the wider learning from deaths processes around PSIRF cam impact on the effectiveness and success of PSIRF itself. These include:

• Incident reporting systems failing to accurately capture incidents and enable an appropriate learning response to be triggered; 
• Superficial /poor quality learning responses/PSIIs, linked to shortcomings in the wider Learning from Deaths and M&M processes which can prevent relevant information being available or forthcoming in a timely way;
• Poor governance record keeping, including a lack of contemporaneous notes or subsequent explanation about the rationale for the choice of learning response;
• Shortcomings in organisational learning/lack of evidence that system learning has been embedded effectively to prevent future deaths; and
• Shortcomings in the collation of records which may result in piecemeal disclosure to the coroner and which may prolong hearings and cause further distresses to family members.

The successful implementation of PSIRF is not limited to those in patient safety and incident investigation roles. To be effective, PSIRF needs to be embraced across an organisation with involvement from Quality Improvement and Organisational Development teams. 

In house legal teams also have a role to play and whilst, in the context of inquests, it is important to remember that there is a fundamental difference between PSIRF and coronial requirements and that evidence gathering must remain distinct, there are significant benefits of collaborative working to meet the aims of both processes.

We hope that our PSIRF Inquest Toolkit for is a useful tool to assist those In-house legal teams preparing for inquest.