Recurring concern

Failure to implement the Patient Safety Incident Response Framework

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First reported 20 Apr 2023•Latest report 28 Mar 2024

Definition

What this concern includes

Includes failures to implement, progress, embed or operationalise the named Patient Safety Incident Response Framework within healthcare organisations, including incomplete rollout and implementation delays that leave the framework's required incident-response arrangements unavailable or ineffective.

Not included

Excludes generic failures to investigate incidents, learn from deaths or implement safety actions where the Patient Safety Incident Response Framework is not explicitly identified.
Excludes deficiencies in the substantive design or adequacy of PSIRF where implementation is not the unsafe condition.
Excludes failures to implement other safety frameworks, alerts, policies or action plans unless the assertion explicitly concerns PSIRF.
Excludes local clinical or operational care failures that are not directly tied to implementation of PSIRF.

Reports: 2
Individual concerns: 3
Date range: 2023–2024
Stated actions: 3

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England1

Norfolk and Suffolk NHS Foundation Trust1

University Hospitals of Derby and Burton NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

28 Mar2024
Suffolk
Concerns raised2
1. Failure to introduce a screening tool for determining PSIRF implementation
2. Failure by NSFT to implement the Patient Safety Incident Response Framework
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Norfolk and Suffolk NHS Foundation Trust is responsible for addressing the care concerns and providing details of PSIRF implementation.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ellen Ocean WOOLNOUGH was found suspended by a ligature at her home on 20 July 2022 after concerns had arisen about her physical and mental health. Resuscitation restored circulation, but she suffered an irreversible hypoxic brain injury and died in hospital on 28 July 2022. The principal concerns relate to mental health service discharge decisions after failed engagement, the response to urgent referrals including risk assessment and safety planning, the implementation of the Patient Safety Incident Response Framework, and the preservation of call recordings and other evidence.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to introduce a screening tool for determining PSIRF implementation
Wider context from the report
“iv. Changes to the way the Trust investigates incidents such as Ellie’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust. ”
Source location
Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure by NSFT to implement the Patient Safety Incident Response Framework
Wider context from the report
“3. Adequacy of the NHS England Patient Safety Incident Response Framework (PSIRF) to address serious incidents concerning patients and the implementation of this framework by NSFT. ”
Source location
Ellen Ocean WOOLNOUGH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.

Verbatim wording from the response
“4. Changes to the way the Trust investigates incidents such as Ellen’s, including the use of a screening tool to determine how the PSIRF process is implemented, the requirement to retain recordings of calls and which statements are to be taken to inform serious patient incident investigations, are still to be introduced by the Trust, and”

Source location
Response from Norfolk and Suffolk NHS Foundation Trust
Page 2 · response
Published 15 April 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Norfolk and Suffolk NHS Foundation Trust is responsible for addressing the care concerns and providing details of PSIRF implementation.

Verbatim wording from the response
“I note that your Report has also been addressed to Norfolk and Suffolk NHS Foundation Trust who are the appropriate organisation to answer the majority of the concerns raised in your Report. NHS England has engaged with the Trust on the issues raised in your Report about Ellen’s care and have been sighted on the action plan and statement submitted to you at inquest. We note from the Trust that their actions include:”

Source location
2024-0184 - Response from NHS England
Page 1 · response
Published 15 April 2024
Open published response
20 Apr2023
Nottinghamshire
Concerns raised1
1. Limited progress in implementing the Patient Safety Incident Response Framework
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Continue implementing the Patient Safety Incident Response Framework through monthly multidisciplinary implementation work and patient-partner involvement.
  Stated by UHDBStated in progress
2. Action
  Agree and establish a Trust-wide incident-management policy and response plan incorporating the Patient Safety Incident Response Framework.
  Stated by UHDBStated planned
AI-generated summary

Jodie Catherine McCann · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Jodie Catherine McCann, a 22-year-old woman, developed gallstone pancreatitis, suffered a cardiac arrest, and required critical care and ventilation. After her tracheostomy tube became displaced and could not be replaced, she suffered a prolonged cardiac arrest caused by lack of oxygen and died. Concerns included inadequate planning and preparation for difficult airway management and tracheostomy displacement, equipment and staffing availability, and delays in the serious incident review.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Limited progress in implementing the Patient Safety Incident Response Framework
Wider context from the report
“The Mortality Review policy was not followed, leading to a significant delay in completing the serious incident review, delaying Trust learning, and delaying the family’s understanding of the circumstances of Jodie’s death. There is limited evidence of progress in implementing the national Patient Safety Incident Response Framework at the Trust ”
Source location
Jodie Catherine McCann · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue implementing the Patient Safety Incident Response Framework through monthly multidisciplinary implementation work and patient-partner involvement.

Verbatim wording from the response
“Implementation of Patient Safety Incident Response Framework (PSIRF)”

Source location
Response from University Hospitals of Derby and Burton NHS Foundation Trust
Page 8 · response
Published 27 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Agree and establish a Trust-wide incident-management policy and response plan incorporating the Patient Safety Incident Response Framework.

Verbatim wording from the response
“The next key step is to agree a Trust wide process and policy for the management of incidents which incorporates and strengthens PSIRF within the organisation.”

Source location
Response from University Hospitals of Derby and Burton NHS Foundation Trust
Page 8 · response
Published 27 April 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to introduce a screening tool for determining PSIRF implementation

Failure by NSFT to implement the Patient Safety Incident Response Framework

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Limited progress in implementing the Patient Safety Incident Response Framework

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Actions described in response 1

Respondent positions 1

Actions described in response 2