What Is PSIRF?
The Patient Safety Incident Response Framework (PSIRF) replaced the former Serious Incident Framework in 2023. It represents a fundamental shift in how NHS trusts respond to patient safety incidents — moving from a blame-focused approach to one centred on learning and system improvement.
PSIRF is now a contractual requirement for all NHS-funded organisations and is increasingly expected in the independent healthcare sector.
Why PSIRF Matters
Under the old framework, organisations were required to investigate every incident that met the "serious incident" threshold using a standardised Root Cause Analysis (RCA) methodology. This often led to:
- Investigations that were formulaic rather than insightful
- Overloaded patient safety teams
- Recommendations that were never implemented
- A culture of fear rather than learning
PSIRF changes this by requiring organisations to develop a Patient Safety Incident Response Plan (PSIRP) that prioritises the types of incidents most relevant to their services and patient population.
How PSIRF-Aligned Investigations Work
Under PSIRF, organisations choose from a range of investigation methodologies based on the nature of the incident:
- Patient Safety Incident Investigation (PSII) — for complex incidents requiring detailed systems analysis
- Swarm huddles — rapid team debriefs held within hours of an incident
- After Action Reviews (AAR) — structured reflections used in other high-risk industries
- Thematic reviews — analysis of patterns across multiple incidents
The goal is to match the right method to the right incident, rather than applying a one-size-fits-all approach.
CQC and PSIRF Compliance
The Care Quality Commission (CQC) now considers PSIRF implementation as part of its assessment of the Safe and Well-led domains. Organisations that can demonstrate effective PSIRF implementation — including evidence of learning and improvement — are more likely to receive positive inspection outcomes.
How CPGB Ltd Supports PSIRF Implementation
Our investigation team includes experienced investigators who have conducted PSIRF-aligned investigations across NHS trusts, mental health services, community providers and the independent sector. We provide:
- Independent Patient Safety Incident Investigations (PSIIs)
- PSIRF implementation support and training
- Thematic reviews and trend analysis
- Expert witness and regulatory support
Get in touch to discuss how we can support your trust's PSIRF journey.