To support the NHS to further improve patient safety, all acute NHS Trusts have implemented the new Patient Safety Incident Response Framework (PSIRF), which replaces the previous Serious Incidents (SI) Framework (2015).

From 1 April 2024, Portsmouth Hospitals University NHS Trust began to respond to patient safety incidents according to PSIRF. The PSIRF is underpinned by modern patient safety science and supports the development and maintenance of an effective patient safety incident response system and will lead to more compassionate engagement and involvement for those affected by patient safety incidents and give staff space for reflection.

An important factor of PSIRF is to understand how incidents happen, and this allows us to learn and improve, in turn creating a safer care system for patient. The four key aims of PSIRF are:

  1. Compassionate engagement and involvement of those affected by patient safety incidents
  2. Application of a range of system-based approaches to learning from patient safety incidents
  3. Considered and proportionate responses to patient safety incidents
  4. Supportive oversight focused on strengthening response system functioning and improvement

Portsmouth Hospitals University NHS Trust’s PSIRF policy and plan has been developed with stakeholder engagement, it supports to identify our most significant patient safety risks and focus on these risks to ensure they are reviewed, with learning and opportunities for improvement identified.

The video below explains PSIRF and how it differs from the SI Framework:

Learn more about PSIRF on the NHS England website.

You may be feeling anxious about being in hospital but keeping you safe and well is a priority for the staff looking after you. There are also some simple things you can do to help keep yourself safe during your hospital stay, such as asking for help when needed, protecting yourself from slips and falls and helping to prevent blood clots.

The ‘Simple steps to keep you safe during your hospital stay’ video and leaflet provides tips on things you can do to look after your safety during your stay.

Check out the 'Simple steps to keep you safe during your hospital stay' leaflet on the NHS England website here.

How will I know if a patient safety incident has occurred?

Portsmouth Hospitals University NHS Trust (PHU) will always be open and honest about incidents that have occurred. In the NHS, this is known as Duty of Candour. If it is believed that something has gone wrong during your care that has caused you moderate or more severe harm, you will be told about this immediately. You will also receive an apology and the circumstances of the incident will be explained to you.

What if I think something has gone wrong or a patient safety incident has occurred?

Please tell the team caring for you immediately, so they can review what happened and provide any immediate treatment that may be required. A family, friend or carer can do this on your behalf if necessary. Once the care team provide the right treatment the incident will be reported and reviewed according to the PSIRF policy and plan to enable the organisation to learn.

What happens if I have been harmed?

Caring for you will be our priority and staff will take immediate action to ensure appropriate treatment is given and to prevent further harm. We will also ensure other support needs are identified.

The incident that has occurred will be recorded in our incident management system and be reviewed against the PSIRF policy and plan and responded to accordingly. You will always be given the facts about the incident that occurred, an apology, and the findings from any review that is undertaken. This information will be provided by the most appropriate person where the incident occurred.

What if I am not happy with the information I receive and/or the response that is taken?

Please raise any concerns with the Matron of the service or contact the Patient Advice and Liaison Service (PALS) so we can work to address any problems or concerns you may have.

What happens if someone has died?

The death of someone, even if expected, can be a very distressing and difficult time for family and loved ones. Dedicated support and information about how we review the care provided to those who have died, including information about Coroner’s inquest, is available via our information guide for bereaved families and through our bereavement team/service.

What can I expect if I am involved in a Patient Safety Incident Investigation?

As soon as a decision is made to start a Patient Safety Incident Investigation related to an incident that affects you, we will be in touch to let you know. The person that contacts you will be your dedicated point of contact. They will try and find a time and place to talk to you about how you want to be involved and supported in the process. You can of course ask a friend or family member to join for support or to speak on your behalf if you don’t feel able to. We will also do all we can to support you.

Your dedicated contact will provide their details and they, or a designated deputy (who you will be introduced to), will be available Monday to Friday.

We are committed to supporting and involving patients and families to the extent they wish, and in accordance with the Guide to engaging and involving patients, families and staff following a patient safety incident.

During the investigation we will ask you to help in several ways. This includes:

  • Telling us about any issues or concerns you have about the care and treatment provided
  • Sharing questions you would like answered
  • Describing your experience and giving your account of what happened to help us establish the facts about the incident and how it happened
  • Reviewing the draft investigation report
  • Helping to inform recommendations and action for improvement
  • Keeping us up to date with how you are feeling and whether there is more we can do to support you
  • Providing feedback about your experience of the Patient Safety Incident Investigation

We will work with you to understand how we can support your involvement in each of these areas, if you are happy to be involved in this way. You may feel you need support from an Independent Advocacy Service, and this will also be discussed with you.

Patient Safety Incident Investigation takes time to complete well. We endeavour to complete all investigations within six months. We will share proposed timeframes with you and keep you updated throughout the investigation process. We can agree in advance how often you would like to be contacted and how.

Once the investigation is complete, we will send you the draft report and arrange a meeting to discuss this with you.

All reports will be anonymised unless you specifically ask us to include your name, or the name of your friend or family member if the investigation relates to an incident that involved them. You can help us to decide how to refer to you, or your friend or family member, if you would prefer the report to be written anonymously.

To support the purpose of learning and improvement and avoid any inappropriate blame, staff will remain anonymous in the final patient safety incident investigation report.

Once the report is finished it will be signed off by a member of the Executive team through the Trust Learning Response Approval Group. Some actions to reduce future risk may need to begin immediately, however, where the findings from other investigations will help our organisation to understand and tackle similar risks, we will wait until all findings can be considered before developing and implementing a safety improvement plan. This will be shared and discussed with you.

We will continue to monitor improvement plans to determine whether the changes we are making are actively reducing risk and improving patient safety. This will be overseen by Portsmouth Hospitals University NHS Trust Learning Response Approval Group and Hampshire & Isle of Wight NHS Integrated Care System (ICS). We will continue to keep you updated with the progress being made.