The future of NHS patient safety investigation


The Serious Incident framework (2015) describes how Serious Incidents should be reported and investigated in the NHS. Between March and June 2018 we sought views on how our guidance could be revised to support the system to respond appropriately when things go wrong.

When something goes wrong with a patient’s care, NHS providers are expected to report these incidents and consider if they meet the definition of a Serious Incident. When Serious Incidents are reported an investigation, which follows guidance set out in the Serious Incident framework (2015), must be undertaken to enable organisations to understand how and why incidents occur, so that changes can be made to prevent recurrence. 

Between March and June 2018, we held a range of engagement activities, including an online survey, asking people to share their views on how and when the healthcare system should investigate and respond to Serious Incidents.

The responses we received are informing the review of the Serious Incident framework in order to provide national guidance on the systems, processes and behaviours providers, commissioners and oversight bodies are expected to adopt to ensure we respond appropriately when things go wrong.

Summary of engagement feedback

The future of NHS patient safety investigation: engagement feedback PDF, 1.7 MB

This document summarises the feedback received through our The future of NHS patient safety engagement activity.

Engagement questionnaire and supporting documents

Our survey closed on 12 June 2018, thank you to all those that took the time to share their views. 

The future of NHS patient safety investigation PDF, 681.6 KB

Please read this information before you start the survey.

An animated video to introduce our engagement programme (note: the recorded webex presentation video is below).

Recorded webex presentation

Watch our 30 minute webex video to learn more about Serious Incident investigation and the five key factors contributing to poor investigation we identify in the discussion booklet. 

This recorded presentation supports NHS Improvement's 'The future of patient safety investigation' engagement exercise. It provides background on Serious Incident investigation and discusses five areas identified as key factors contributing to poor investigation.

Events and social media

As part of our engagement programme we hosted four workshops to bring together people associated with patient safety, from a variety of roles and backgrounds, to further explore how and when the NHS should investigate patient safety incidents:

#WeNurses tweet chat

On Thursday 24 May we hosted a #WeNurses Tweetchat as a further way to engage and seek your views about how and when the healthcare system should investigate serious incidents. View a summary of the chat and transcript of the posted comments.

Updates about the engagement programme will also be posted on this page and via our Twitter accounts @NHSImprovement and @ptsafetyNHS using #PSInvestigation2018.

Next steps

We are now in the process of designing and drafting the next Serious Incident Framework using the feedback we received, and we are continuing to work with partners and stakeholders to develop this. We aim to publish in Spring 2019.

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