First reported 5 Jun 2025•Latest report 14 Oct 2025
Definition
What this concern includes
Includes failures in the explicitly named PSIRF or Patient Safety Framework process for recording and assessing safety incidents, deciding whether investigation is required, preserving relevant decision information, and evidencing resulting reflection, remediation or learning.
Not included
Excludes failures to implement PSIRF as a framework where the asserted deficiency is rollout or operationalisation rather than the safety-incident decision and learning process itself.
Excludes generic clinical-record, incident-reporting or organisational-learning failures that are not explicitly tied to the PSIRF or Patient Safety Framework process.
Excludes failures in the underlying clinical care or incident where no deficiency in PSIRF decision-making, information or learning is identified.
Excludes unrelated safety-action implementation failures after PSIRF learning has been reliably established.
Reports
4
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2025–2025
First to latest report issue date
Stated actions
11
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Barts Health NHS Trust2
Barking, Havering and Redbridge University Hospitals NHS Trust1
Department of Health and Social Care1
Essex Partnership University NHS Foundation Trust1
NHS trust4
Ministerial department1
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.
East London
Concerns raised1
Failure to provide complete evidence of reflection and remediation
This report raised 2 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
East London
Concerns raised2
Failure of patient safety governance to identify incidents requiring investigation
Failure of patient safety governance to reflect upon and remediate sub-optimal practice
This report raised 2 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2025.
East London
Concerns raised2
Failure of governance processes to remediate sub-optimal practice
Failure to identify incidents requiring investigation through the Patient Safety Framework
This report raised 4 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Action
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Issue Trust-wide communication requiring significant or unexpected complications to be recorded on Datix for PSIRF consideration.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2025.
Action
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to maintain accurate and complete PSIRF decision-monitoring information
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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.3
Action
Amend and implement the PSIRF Decision Monitoring Tool template.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
Action
Require Care Unit leadership multidisciplinary discussion and sign-off for every completed Decision Monitoring Tool or investigation.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
Action
Apply final scrutiny to Decision Monitoring Tools at sign-off by central Patient Safety and Executive Director-level staff.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 June 2025.
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Includes failures in the explicitly named PSIRF or Patient Safety Framework process for recording and assessing safety incidents, deciding whether investigation is required, preserving relevant decision information, and evidencing resulting reflection, remediation or learning.
