Bridging the gap: Patient safety incident response framework and the coronial process

Healthcare providers are adapting to a new approach to patient safety investigations following the introduction of the Patient Safety Incident Response Framework (PSIRF) in August 2022. PSIRF has transformed the investigation process, placing greater emphasis on organisational learning rather than assigning blame. This change is creating challenges between PSIRF and coronial inquests, says NHS England.

A recent communication seen by the Health Service Journal between NHS England and the Chief Coroner addresses coroners’ concerns about “inadequate” NHS Trust patient safety reports and with some patient deaths not investigated through PSIRF.

PSIRF represents a shift away from the traditional Root Cause Analysis (RCA) reports under previous Serious Incident Investigations, with its purpose to support candid exploration of systems, processes and culture and not to attribute blame or determine how someone died.

Under the coronial process, coroners have a statutory duty to answer four questions, including how the deceased came by their death which often requires the coroner to determine findings on causation.

This shift has led to some tension between the two processes as coroners had previously come to rely on the previous RCA reports for chronologies but under PSRIF those no longer exist.

NHS England’s recent communication outlines specific points for clarification:

• PSIRF reports must not be used as the primary evidence in an inquest. They can still add value but in a supplementary context. For example, supporting the coroner to understand the system-wide context, in particular where they may be considering issuing a Regulation 28 or Preventing Future Death report.
• Coroners should not expect RCA style investigations
• Coroners may need to obtain causation evidence through other routes, such as experts reports or witness statements

Comment

This update serves as a timely reminder for healthcare providers of the need to collaborate effectively with coroners in identifying relevant material - such as witness statements and expert evidence - ahead of an inquest hearing. In addition, providers must be prepared to manage family expectations with honesty and sensitivity, clarifying both the nature of the PSIRF process and what to anticipate during the inquest.

Our inquest team are advising providers across the country, do contact us if you require support.  

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