Understanding the PSIRF Investigation Process
When a patient safety incident occurs in the NHS, organisations must now respond using the Patient Safety Incident Response Framework (PSIRF). But what does that actually mean in practice? Here's what happens, step by step.
Step 1: Incident Detection and Initial Response
When an incident occurs or is identified, the organisation's patient safety team assesses it against their Patient Safety Incident Response Plan (PSIRP). This plan — unique to each organisation — defines which types of incidents warrant which type of response.
The initial focus is always on:
- Immediate safety — ensuring the patient and others are safe
- Duty of candour — being open and honest with the patient and family
- Preserving evidence — securing records, statements and relevant documentation
Step 2: Determining the Response Type
Under PSIRF, not every incident requires a full investigation. The organisation selects the most appropriate response:
- Patient Safety Incident Investigation (PSII) — for incidents requiring detailed systems analysis
- Swarm huddle — a rapid, team-based debrief held within hours
- After Action Review (AAR) — a structured reflection on what happened
- Thematic review — examining patterns across multiple related incidents
This is a fundamental change from the old Serious Incident Framework, which applied a one-size-fits-all Root Cause Analysis to every qualifying incident.
Step 3: Commissioning the Investigation
If a PSII is required, the organisation must decide whether to investigate internally or commission an independent investigation. Independent investigations are typically commissioned when:
- The incident is high-profile or involves significant public interest
- There are concerns about organisational independence or objectivity
- The incident spans multiple services or agencies
- Regulatory bodies or commissioners require independent oversight
- The family has requested independent involvement
At CPGB Ltd, we are regularly commissioned to lead independent PSIIs for NHS trusts, mental health services and community providers.
Step 4: Setting Terms of Reference
Every investigation begins with clear terms of reference that define:
- The scope and timeframe of the investigation
- The specific questions to be explored
- How the patient or family will be involved
- The expected outputs and timeline
- Governance and reporting arrangements
Good terms of reference are focused and proportionate — they ask the right questions without creating an unmanageable scope.
Step 5: Evidence Gathering and Analysis
The investigation team gathers evidence from multiple sources:
- Clinical records — notes, observations, prescribing records
- Staff interviews — conducted compassionately and without blame
- Policy and procedure review — checking what should have happened
- Environmental and contextual factors — staffing, workload, equipment
- Family and patient accounts — understanding the lived experience
Evidence is analysed using systems-based methodology, looking for contributory factors at individual, team, organisational and system levels.
Step 6: Family Involvement
PSIRF places strong emphasis on meaningful family involvement. This means:
- Offering families a single point of contact
- Explaining the investigation process in plain language
- Agreeing how and when families would like updates
- Giving families the opportunity to contribute their perspective
- Sharing findings before the report is finalised
At CPGB Ltd, we treat family involvement as a core part of our methodology, not an afterthought.
Step 7: Report and Recommendations
The investigation produces a clear, structured report containing:
- A factual chronology of events
- Analysis of contributory factors using systems thinking
- Findings linked to evidence
- Actionable recommendations that specify who needs to act and what needs to change
Recommendations must be practical and implementable — not vague statements that sit in a drawer.
Step 8: Learning and Improvement
The final step is translating findings into real improvement. This means:
- Sharing learning across the organisation
- Tracking implementation of recommendations
- Monitoring whether changes are sustained
- Feeding insights into the organisation's Patient Safety Incident Response Plan
How CPGB Ltd Supports PSIRF Investigations
Our team of NMC, GMC and HCPC registered professionals has led PSIRF-aligned investigations across NHS trusts, mental health services and community healthcare. We provide:
- Independent Patient Safety Incident Investigations (PSIIs)
- Multi-agency and cross-boundary investigations
- Family liaison and compassionate engagement
- Expert clinical review and peer oversight
- PSIRF implementation support and training
Contact us to discuss how we can support your investigation needs.