Recurring concern

Failure to implement the Patient Safety Incident Response Framework

First to latest report 20 Apr 2023 — 28 Mar 2024

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
3

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.

What is 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 and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Suffolk

    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

  2. Nottinghamshire

    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

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026