Unreliable PSIRF safety-incident decision and learning processes
First to latest report 5 Jun 2025 — 14 Oct 2025
Reports that mention this concern
4
Times this concern has been raised
6
Stated actions linked to this concern
11
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 4 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barking, Havering and Redbridge University Hospitals NHS Trust
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.
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.
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
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.
Linked responses
Barts Health NHS Trust
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Barts Health NHS Trust
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Barts Health NHS Trust
Issue Trust-wide communication requiring significant or unexpected complications to be recorded on Datix for PSIRF consideration.
Barts Health NHS Trust
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Barts Health NHS Trust
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Barts Health NHS Trust
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Barts Health NHS Trust
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Redirects 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
Linked response
Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Essex Partnership University NHS Foundation Trust
Amend and implement the PSIRF Decision Monitoring Tool template.
Essex Partnership University NHS Foundation Trust
Require Care Unit leadership multidisciplinary discussion and sign-off for every completed Decision Monitoring Tool or investigation.
Essex Partnership University NHS Foundation Trust
Apply final scrutiny to Decision Monitoring Tools at sign-off by central Patient Safety and Executive Director-level staff.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.