The interface between PSIRF and inquests

As we hurtle through 2024 and with the Patient Safety Incident Response Framework (PSIRF) operational for approximately six months we thought a reminder of some of the key principles might be helpful at this point in time.


As those involved in risk management will know, under PSIRF, NHS organisations and independent provider organisations that provide NHS-funded secondary care under the NHS Standard Contract are required to adopt this framework. They must investigate any “unintended or unexpected events (including omissions)” which could have caused or caused harm to patients. The investigation has been described as a “window into the system”.

The PSIRF approach allows for a range of methods to support learning from patient safety incidents and therefore inform improvement, beyond investigations, recognising that there's no “one size fits all” approach. It’s all about the opportunity for learning with fewer but higher quality investigations.

As readers will know, PSIRF replaces the Serious Incident or SI framework and removes the “serious incident” classification for investigation.

PSIRF and inquests

PSIRF is changing the way both NHS organisations and independent providers undertake investigations and the reports that are disclosed to coroners. The Patient Safety Incident Investigation (PSII) report is different to the previous SI report.

Under the new framework, and the PSII response activities it supports it “explicitly excludes activities that apportion blame or determine culpability, determine preventability, or identify cause of death.” The PSII is limited to the investigation process and learning from the incident – you can view NHS England’s PSII template report here.

So, PSIRF reports are unlikely to be sufficient for an inquest with complex points on causation and PFD matters.

The framework recognises that some patient safety incidents may also require a separate response that is not focused on learning for patient safety improvements – and states that it's important that these incident investigations are conducted separately. For example, some incidents where a patient dies may give rise to a coroner’s investigation, others may involve the police. Similarly, some incidents about a healthcare professional’s fitness to practise may give rise to investigations by a professional regulator or employer. Care must, therefore, be taken not to blend patient safety incident response activity with providing reports for other purposes such as inquests and claims.

Top 10 points to note

  • Documents and coroners: Do your local coroners fully understand PSIRF, your PSIRF policy and plan that guides your response to a Patient Safety Incident. Have you been able to discuss the documentary evidence that they'll generally find helpful?
  • PFDs: Regulation 28 or Preventing Future Deaths reports remains unchanged by PSIRF. So the onus remains to present evidence to assure the coroner that the Regulation 28 duty is not triggered. Responsibility remains with the NHS provider or independent provider organisation to disclose all the relevant documentation and evidence to the coroner to minimise the risk of a PFD being issued and present organisational learning.
  • Disclosure: Not all deaths reviewed by a coroner will receive a full PSII; however, if a PSII report has been prepared then it'll need to be disclosed to the coroner as part of the disclosure exercise.
  • Witness statements: Witness statements are no longer required as part of the PSII or learning response. Staff will continue to require support with any statements produced separately for a coroner or inquest hearing.
  • No PSII: Do consider in what ways and how you present your evidence and organisational learning to a coroner. If there's no PSII, how will you present the output of an MDT or case review or huddle etc.
  • PSII: These are different to the old Serious Incident Reports and there is not judgment on the cause of death or causation.
  • Causation: Whether or not a PSII as been prepared give careful thought to causation evidence.
  • Duty of Candour: Is not affected by PSIR.
  • Quality assurance: Ensure documents created are accurate and stored appropriately eg Improvement Plans (so they can be audited).
  • Litigation: Remember the outputs of your PSII or learning response will be disclosable as part of any claims.

Training and support

If your organisation requires support with the interface between PSIRF and inquests or the management of a PFD report, please don't hesitate to get in touch with a member of our expert inquest team.

Our content explained

Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.

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