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.

Introduction of the Patient Safety Incident Response Framework

Using feedback we received via our engagement activity (see below), and as committed to in the recently published NHS patient safety strategy and NHS Long Term Plan, we have developed a new Patient Safety Incident Response Framework (PSIRF) to replace the existing Serious Incident Framework.

We aim to publish the new framework in Autumn 2019 as introductory guidance. We will initially work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only.

Using learning from the pilot sites, we will develop resources and guidance to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin introducing the new framework from Autumn 2020, with full NHS-wide roll out complete by Summer 2021.


  • Autumn 2019 - PSIRF published as introductory guidance and NHS England and NHS Improvement begin work with a small number of early adopters.
  • From Autumn 2020 - local systems and organisations outside of the early adopter areas will be encouraged to move across to the new framework.
  • By summer 2021 - all parts of the NHS in England expected to use PSIRF.

Until an organisation has formally moved over to PSIRF, they are expected to continue to abide by the existing Serious Incident Framework and all its relevant reporting, incident investigation and management requirements.

What providers need to do

When the PSIRF is published all parts of the NHS should familiarise themselves with it and start to think about the steps they will need to take within their organisation or local system to adopt this new approach.

Working with early adopter sites and publishing the PSIRF well ahead of system-wide adoption ensures we are able to learn how organisations and systems can introduce the new framework most effectively and gives local organisations and systems the opportunity to fully prepare to embed the principles and requirements of the new framework.

Our engagement activity

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 development of the Patient Safety Incident Response Framework that will replace the Serious Incident framework 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.

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