Patient safety incident response policy and plan

Contents

1 Foreword

“The introduction of this framework represents a significant shift in the way the NHS responds to patient safety incidents, increasing focus on understanding how incidents happen, including the factors which contribute to them. “ Aidan Fowler, National Director of Patient Safety, NHS England.

The patient safety incident response framework (PSIRF) is being adopted by the whole of the NHS and a new way to manage patient safety incidents. Replacing the current serious incident framework (SIF), it sets a clear direction for responding to patient safety incidents, focusing on the system in which incidents occur, understanding how they happen and avoiding blame.

This policy supports the requirements of the PSIRF framework and sets out Rotherham, Doncaster and South Humber NHS Foundation Trusts’ (RDaSH) approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

2 Purpose

This policy is based on NHS England’s Patient Safety Incident Response Framework (PSIRF) 2022 (opens in new window) as per the NHS Standard Contract and sets out the Rotherham, Doncaster and South Humber NHS Foundation Trust approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

The PSIRF advocates a co-ordinated and data-driven response to patient safety incidents. It embeds patient safety incident response within a wider system of improvement and prompts a significant cultural shift towards systematic patient safety management.

The health, safety and welfare of its service users, staff and visitors is a key priority for the trust. It will work closely with partner organisations, third sector organisations and where applicable volunteer groups to ensure collaborative learning at all levels.
This policy supports development and maintenance of an effective patient safety incident response system that integrates the four key aims of the PSIRF:

• compassionate engagement and involvement of those affected by patient safety incidents.
• application of a range of system-based approaches to learning from patient safety incidents.
• considered and proportionate responses to patient safety incidents and safety issues.
• supportive oversight focused on strengthening response system functioning and improvement.

Effective patient safety management and response relies on having a positive learning culture where staff are keen to learn from incidents and events, has an effective incident reporting process and where robust and shared investigation and learning takes place.

This policy should be read in conjunction with our current patient safety incident response plan which is a separate document setting out how this policy will be implemented.

It should also be read in conjunction with the trust clinical and organisational strategy.

3 Scope

This policy relates to responses to patient safety incidents that are solely for the purpose of learning and improvement across the trust.
Responses under this policy follow a systems-based approach. A system-based approach recognises that healthcare takes place in a work system composed of people, tasks, equipment and the different environments in which care is provided. All these aspects of the system vary and interact with each other to produce different outcomes

Responses do not take a person-focused approach where the actions or inactions of people, or human error, are stated as the cause of an incident. Supporting staff to be open allows valuable lessons to be learnt so the same errors can be prevented from being repeated.

When responding to incidents and safety events under PSIRF, the aim is on learning for improvement and there is no remit to determine liability, preventability, or cause of death. Other processes outside of the scope of this policy are listed below:

• claims management
• human resources investigations into employment concerns
• professional standards investigations
• coronial inquests
• criminal investigations
• information governance concerns
• medical examiner review
• estates and facilities concern
• financial investigations and audit
• complaints and safeguarding concerns (except where a significant patient safety concern is highlighted)

Information from a patient safety response process can be shared with those leading other types of responses, but other processes will not influence the remit of a patient safety incident response.
This policy should be read in conjunction with the following other trust policies:

• freedom to speak up policy: raising concerns (whistleblowing) policy
• being open policy (incorporating the duty of candour)
• learning from deaths policy the right thing to do

4 Our patient safety culture

RDaSH is ambitious about driving change and improvement for our patients, staff and local communities. RDaSH has a 2023 to 2028 trust strategy which sets out our ambitions to improve health and care for local people and to strive to create a workplace climate and an organisational culture which is responsive, supportive, and restorative, where good practice is shared and we promote a learning environment for all.

Having a restorative just and learning culture of openness within the organisation means that staff do not feel afraid of reporting adverse events or feel blamed when they are involved in an incident. In this way learning can take place and improvements made locally and which can be shared across other services.

The Just Culture guide (opens in new window) does not replace the need for patient safety investigation and will not be used as a routine or integral part of these.

RDaSH is committed to promoting and improving the quality and safety of care and treatment all patients receive, as well as preserving the safety of its staff, visitors, and others. A safety conscious organisation is one which is receptive to adverse incidents so it can learn, develop, and change practice. We have embedded these principles into our procedures for the review of incidents.

RDaSH promotes the reporting of incidents including near misses as an opportunity to learn and to improve safety and services. Staff will also be supported through the freedom to speak up policy: raising concerns (whistleblowing) policy.

Alongside the opportunities to learn from incidents, the trust is committed to learning from excellence and doing this through the reporting of excellence and reflecting on opportunities to make care currently considered as excellence, the future standard care within the trust.

PSIRF will create much stronger links between a patient safety incident and learning and improvement. We will work with those affected by a patient safety incident to drive learning and improvement.

We will work together with staff to embed the approach whereby patient safety incident responses are the drivers for learning and improvements to reduce risk.

We have launched our learning from patient safety incident frameworks (LFPSE) and have safety huddles at all levels of the organisation which allow us time to consider our risks and to identify any learning.

We will use our data including our staff survey results to monitor our ongoing progress in improving our safety culture.

The following meetings have been put in place to enhance our safety culture across the trust:

• daily incident meetings, these are chaired by the Patient Safety team
• weekly patient safety huddle, these are chaired by the deputy director for organisational learning, patient safety and inquests or deputy
• within the meeting learning, trends and themes from the daily incident meetings held during the week are reviewed and discussed to identify actions to be taken and responses
• patient safety incident response review group (PSR) is chaired by the director of safety and quality or in their absence by the deputy director for organisational learning, patient safety and inquests. This takes place monthly and will review patient safety incident investigations (PSII)’s completed that month as well as any after action reviews, SWARM huddles or thematic analysis reviews undertaken by the care groups or the Patient Safety team
• triangulation of patient safety information occurs monthly with the Patient Safety team (PST), complaints, PALS and claims

RDaSH recognises the significant impact being involved in a patient safety incident can have on staff and will ensure staff receive the support they need to positively contribute to the review of the incident and continue working whilst this takes place.

• The Patient Safety team will advise, and signpost care groups and staff involved in patient safety incidents to the most appropriate information about the patient safety incident review process and further support functions.
• Schwartz rounds. Sessions are themed and provide a structured forum and safe space where staff come together to discuss the emotional and social impact of working in healthcare. You can join the conversation, share your experience or simply listen to their stories.
• Freedom to speak up guardian, a confidential service for staff if they have concerns about the organisation’s response to a patient safety incident.
• Support from patient safety incident investigators for those involved in a patient safety incident investigation
• Chaplaincy can provide support as needed.
• Referral for support or counselling through your manager which may include the post incident response service.

The trust will ensure that all patient safety incidents are managed and investigated based on the need to learn. Data will be reviewed to identify any themes and trends which will inform whether there is a need for further investigation.

5 Addressing health inequalities

The trust recognises that the NHS has a core role to play in reducing inequalities in health by improving access to services and tailoring those services around the needs of the local population in an inclusive way. Addressing health inequalities is an organisational priority and will feature in a range of quality improvement and quality assurance processes.

Reducing health inequalities is a key objective running through the trust’s clinical strategy with the need to work together through a community powered approach. We know that there are many factors that can affect inequalities. These inequalities can often mean differences in a person’s access, engagement, outcomes, experience and opportunities. All this can impact on a person’s life chances and in some cases their risks.

Inequalities affect patients and their safety, people with a protected characteristic can face inequalities in terms of their care and safety, and having more than one protected characteristic may accentuate that inequality. We will ensure, through our data collection and analysis that we identify any disproportionate risk to patients with specific characteristics, which can in turn inform patient safety incident responses.

When undertaking our reviews and subsequent actions we will consider whether there are any areas of health inequalities and whether these have contributed to risk or harm. This will include all protected characteristics. Findings will feed into our trust work streams around transformation or quality improvement.

As part of the ongoing review of our plan we will work to identify variations that signify potential inequalities by using our population data and our patient safety data to ensure that this is considered as part of the development process for future versions of our patient safety incident response plan.

When completing our reports and plans we will use available tools such as easy read, translation and interpretation services and other methods as appropriate to meet the needs of those concerned and maximise their potential to be involved in our patient safety incident response.

Patient safety incident responses will continue to consider health inequalities through a variety of routes. These routes will consider:

• outcomes for patients across a range of specific characteristics to ensure any unwarranted variation is identified as an area for improvement for consideration
• specific support needs to encourage engagement in patient safety responses from all patients, focusing on what each person can add to the learning process and collectively removing any barriers to participation
• during recruitment of PSPs consideration will be given to diversity and where gaps in partners with specific characteristics are identified, active recruitment will be led to ensure diversity in this key stakeholder group

When engaging and involving patients, families, carers or staff following a patient safety incident we will take into consideration their different needs, including but not limited to:

• black and minority ethnic groups
• people with a learning disability and autistic people
• people with dementia
• people who need accessible communication including Deaf people and people who do not speak English
• lesbian, gay, bisexual and transgender people

The trust will ensure that staff have the relevant training and skill development to support this approach.

6 Engaging and involving patients, families and staff following a patient safety incident

PSIRF recognises that learning and improvement following a patient safety incident can only be achieved if supportive systems and processes are in place. It supports the development of an effective patient safety incident response system that prioritises compassionate engagement and involvement of those affected by patient safety incidents (including patients, families and staff). This involves working with those affected by patient safety incidents to understand and answer any questions they have in relation to the incident and signpost them to support as required.

The trust is committed to creating a culture of openness with patients, families and carers particularly when clinical outcomes are not as expected or planned. There is a responsibility as well as a statutory requirement under CQC regulation 20, duty of candour for all healthcare organisations to be open and transparent with patients and their families when things go wrong with treatment or care delivery. In accordance with the trust’s being open policy (incorporating the duty of candour), investigators will involve the patients, their family or carers in the investigation process unless there is an identified and documented reason not to do so.

When engaging after a patient safety incident, all patients and families will be treated with respect, dignity, openness, and transparency at all times. The term engagement describes everything an organisation does to communicate with and involve people affected by a patient safety incident in a learning response. This may include the duty of candour notification or discussion. PSIRF emphasises the need for compassionate engagement which prioritises and respects the needs of people who have been affected by a patient safety incident.

Those affected by patient safety incidents will be:

• provided with a named main contact with whom to liaise about any learning response and support
• communicated with in a way that takes account of their needs
• fully informed about what happened
• given the opportunity to provide their perspective on what happened
• given an opportunity to raise questions about what happened and to have these answered openly and honestly
• helped to access counselling or therapy where needed
• given the opportunity to receive information from the outset on whether there will be a specific learning investigation and what to expect from the process
• signposted to where they can obtain specialist advice and, or advocacy and, or support from independent organisations regarding learning response processes
• allowed to bring a friend, family member or advocate of their choice with them to any meeting that is part of the learning response process they are involved in
• informed who will conduct any learning investigation and of any changes to that arrangement
• given the opportunity to input to the terms of reference for the investigation, including being given the opportunity to request the addition of any questions especially important to them (note this does not mean that their requests must be met, but they must have any decision not to meet their request explained to them)
• given the opportunity to agree a realistic timeframe for any investigation
• informed in a timely fashion of any delays with the investigation and the reasons for them
• updated at specific milestones in the investigation should they wish to be
• given the opportunity to review the learning report with a member of the investigation team while it is still in draft and there is a realistic possibility that their suggestions may lead to amendments, note this does not mean that their suggestions must be incorporated but any decision not to incorporate their suggestions must be explained to them
• invited to contribute to the development of safety actions resulting from the learning report
• given the opportunity to feedback on their experience of the learning response and report (for example, timeliness, fairness, and transparency)

6.1 Four steps of engagement

6.1.1 Before contact

• Identify the family contact.
• Assess inclusivity need.
• Assess potential support needs.
• Ensure familiarity with incident.
• Assess potential for parallel responses and prepare guidance.

6.1.2 Initial contact

• Provide a clear introduction.
• Offer a meaningful apology.
• Identify key point of contact.
• Explore support needs.
• Discuss the incident.
• Explain what happens next.
• Address questions.
• Schedule or discuss next contact (if required).

For investigation:

• confirm involvement preferences

6.1.3 Continued contact

• Agree timeframe for responding to questions.
• Revisit support needs.
• Check for additional questions.
• Share experience of the incident.

For investigation:

• define or discuss terms of reference
• agree timeframe for completion of investigation
• revisit involvement preference
• discuss report preferences
• share the draft report

6.1.4 Closing contact

• Address questions.
• Reiterate meaningful apology.
• Final contact (formal end).
• Ongoing support.

For investigation:

• final report
• discuss any further investigations
• opportunities for further involvement

The trust has a patient advice and liaison service (PALS). People with a concern, comment, complaint or compliment about care or any aspect of the trust services are encouraged to speak with a member of the Care team. Should the Care team be unable to resolve the concern then PALS can provide support and advice to patients, families, carers, and friends. PALS is a free and confidential service and the PALS team act independently of clinical teams when managing patient and family concerns. The PALS service will liaise with staff, managers and, where appropriate, with other relevant organisations to negotiate immediate and prompt solutions.

PALS can help and support with the following:

• advice and information
• comments and suggestions
• compliments and thanks
• informal complaints
• advice about how to make a formal complaint

If the PALS team is unable to answer the questions raised, the team will provide advice in terms of organisations which can be approached to assist.

We recognise that there might also be other forms of support that can help those affected by a patient safety incident and will work with patients, families, and carers to signpost to their preferred source for this.

To monitor our effectiveness a post learning response questionnaire will be issued to patients and, or their families affected by patient safety incidents.

6.2 Post incident

The line manager or person in charge must ensure all staff and service users involved in a traumatic or stressful incident are offered support following an incident. Staff may suffer high levels of stress and distress immediately after an incident and throughout the investigation and learning period. It is imperative, to maintain both staff wellbeing and service user safety and to ensure that staff are well supported throughout the process.

A swarm huddle should be held as soon after the event as possible to allow staff the opportunity to reflect on the situation and explore how it has made them feel. This would usually be organised and facilitated by the ward or team manager. These may be supported by the Post Incident Response team.

All incidents involving the use of restrictive interventions must be subject to a post incident review facilitated by an appropriately identified clinician. The review must include the views of the service user where possible and all staff involved in the incident.

Where a patient safety incident investigation (PSII) has taken place the team(s) should be supported to collaborate in the development of learning action and a debrief and a learning event must be held within the staff team(s) to share the findings of the investigation and to enable reflection and learning to be undertaken.

Guidance on engaging patients, family and staff can be found at the NHS England website (opens in new window).

7 Patient safety incident response planning

PSIRF supports organisations to respond to incidents and safety issues in a way that ensures we identify and capture learning and improvement rather than basing responses on definitions of harm. Organisations can explore patient safety incidents relevant to their context and the populations they serve rather than exploring only those that meet a certain nationally defined threshold. Beyond nationally set requirements, we as a trust have explored the key patient safety incidents relevant to the organisation and their populations rather than only those that meet a certain threshold.

The trust will take a proportionate approach to its response to patient safety incidents to ensure that the focus is on learning and improvement. The trust approach will align to the documents “Guide to responding proportionately to patient safety incidents” and the “Patient safety Incident response standard’s”.

Our patient safety incident response plan (PSIRP) was developed using 3 years of previous incident, serious incident, and complaint data together with the trust claims profile to identify our highest safety risks to focus on as priorities for systems-based investigation.

7.1 Resources and training to support patient safety incident response

The trust has committed to ensuring that we fully embed PSIRF and meet its requirements. A range of resources to support patient safety incident investigations and learning responses are available through the patient safety incident response framework and these have been adopted by the trust. Investigation templates and supportive guidance for learning responses are available on the PSIRF webpage on the trust Intranet.

All systems-based patient safety incident investigations will be carried out by a patient safety incident investigator. Part of the Patient Safety team, they will have undertaken specific training in systems-based investigation methodology delivered by the health services safety investigations body and will complete the 2 day level 2 learning from patient safety incidents training. Training for managers and care group reviewers is being sourced. Training will be subject to ongoing review and development as the trust embeds the principles of the PSIRF.

Those staff affected by patient safety incidents will be afforded the necessary managerial support and be given time to participate in learning responses.

7.2 Our patient safety incident response plan

Our plan sets out how the trust intends to respond to patient safety incidents over a period of 12 to 18 months. The plan is not a permanent set of rules that cannot be changed. We will remain flexible and consider the specific circumstances in which each patient safety incident occurred and the needs of those affected, as well as the plan.

7.3 Reviewing our patient safety incident response policy and plan

Our patient safety incident response plan is a living document that will be appropriately amended and updated as we use it to respond to patient safety incidents. We will review the plan every 12 to 18 months to ensure our focus remains up to date and in line with our patient safety incident profile. It also provides an opportunity to re-engage with stakeholders to discuss and agree any changes made in the previous 12 to 18 months.

Updated plans will be published on our website, replacing the previous version.

A rigorous planning exercise will be undertaken every four years and more frequently if appropriate (as agreed with our integrated care board (ICB)) to ensure efforts continue to be balanced between learning and improvement. This more in-depth review will include reviewing our response capacity, mapping our services, a wide review of organisational data (for example, patient safety incident investigation (PSII) reports, improvement plans, complaints, claims, staff survey results, inequalities data, and reporting data) and wider stakeholder engagement.

8 Responding to patient incidents

8.1 Patient safety incident reporting arrangements

All staff are responsible for reporting any potential or actual patient safety incident on the trust Ulysses risk management system and will record the level of harm they know has been experienced by the person affected.

Incidents must be reported as soon as possible following the event and wherever possible, before the end of the working day the incident occurred in. It is expected that all incidents will be reported within 24 hours of them occurring. The daily incident meeting will monitor any patterns of delays in incident reporting and report back to the care group.

When an incident is deemed to have caused significant physical or psychological harm to a patient(s), the following applies:

• Monday to Friday 9am to 5pm, the incident must be recorded on Ulysses as soon as possible. The classification of harm must be accurately selected. The person in charge of the ward or service must be informed as soon as possible to assist in the management of the incident, support of all service users and staff involved and preservation of the scene or evidence if this is required

Out of hours 5pm to 9am, the incident must be logged, managed and reported as above, additionally, the manager or person in charge must contact the silver on-call manager, who will then notify the gold on call director.

If the event is a never event the Patient Safety team must be informed on rdash.patientsafetyteam@nhs.net.

8.1.1 Initial response to an incident

When a significant patient safety incident occurs on trust property, staff involved must:

• secure the area as required by the circumstances of the incident
• ensure the safety of all those affected by the patient safety incident and provide emergency or life-saving care if required
• ensure the safety of the environment, in the most serious of patient safety incidents this may need to be kept secure to aid with any potential police investigation
• notify emergency services as appropriate or required, for example, Fire and Rescue, Ambulance and, or South Yorkshire Police
• ensure any equipment involved in the incident is retained in a safe area for further examination or inspection or calibration
• offer support where required
• notify the service user’s next of kin or nominated individual (if or where applicable)
• escalate to manager during working hours and silver on call manager out of hours and weekends
• report the incident on Ulysses, ensuring this accurately records the facts and any harm caused
• write down their recollection of events, as soon after as practically possible, to aide memory capture and information gathering to assist future learning
• attend swarm huddle or briefings and, or interviews, as required, in conjunction with their team or service manager and the lead investigator, in order to gather information and understand the learning

8.1.2 Reviewing an incident

All incidents reported in the preceding 24-hour period (midnight to midnight) will be reviewed in the daily incident meeting (DIM) on a Monday to Friday. Incidents that occur over the weekend will be discussed at the Monday meeting. The DIM is made up of representatives across care groups quality, safety, pharmacy, safeguarding, etc and every incident is considered individually to identify any learning, staff support and, or to raise or escalate patient safety concerns, themes and trends.

All incidents that have been identified as needing further actions or discussion will be reviewed in the weekly safety incident huddle. This will be chaired by the deputy director for organisational learning, patient safety and Inquest on in their absence by the head of investigations.

Most incidents will only require local review within the service. However, for some, where it is felt that the opportunity for learning and improvement is significant, further information may be required and an early learning review template may be completed.

Some incidents may require a patient safety incident investigation (PSII) and an immediate escalation may be required. These will be escalated to the executive medical director and the executive director of nursing and allied health professionals by the deputy director. The local and national incidents that require this response include:

• a homicide or attempted homicide by a service user in receipt of (or has been in receipt of within the previous 6 months) services provided by the trust
• an inpatient death
• a never event
• an incident that may lead to media attention or reputational risks
• deaths thought more likely than not to have been due to problems in care (for example, incidents meeting the learning from deaths criteria)

8.2 Patient safety incident response decision making

The trust will have arrangements in place to allow it to meet the requirements for review of patient safety incidents under PSIRF. Some incidents will require mandatory PSII, others will require review by, or referral to another body or team depending on the event. These are set out in our PSIRF plan.

Our patient safety incident response plan (PSIRP) supports the proactive allocation of patient safety incident response resources, but there will always need to be a reactive element in responding to incidents. Where a patient safety incident indicates an unexpected level of risk and, or potential for learning and improvement but it falls outside the issues or specific incidents described in our PSIRP, decisions-making will be led by the deputy director for organisational learning, patient safety and inquests in consultation with members of the patient safety incident review group and executive colleagues.

8.2.1 Patient safety incident response

8.2.1.1 Initial steps

1. Patient safety incident recorded.
2. Daily incident meeting identify any early actions and if further review required.
3. Staff support, ensure duty of candour is actioned when indicated.

8.2.1.2 Decision making

1. Patient Safety team, MOG, or care group to review the patient safety incident against the trust patient safety incident response plan (PSIRP). Is an automatic PSII indicated?
   • yes, go to 8.2.1.3 Action taken, path 1
2. No, is this type of patient safety incident included within the trusts PSIRP?
   • yes, go to 8.2.1.3 Action taken, path 2
3. No, discuss with the patient safety team whether this patient safety incident, when considered alongside others, highlight a changing or new or emerging risk which may need to be explored?
   • no, go to 8.2.1.5 No further action
   • yes, Patient Safety Investigation team to decide most proportionate response (capture rationale). Go to 8.2.1.3 Action taken, path 2

8.2.1.3 Action taken, path 1

1. The Patient Safety Investigation team undertakes PSII investigation.
2. All learning responses must be undertake using a system bested approach to:
   • gather information
   • involve those affected where possible (both staff and families or carers or patients)
   • define areas for learning and improvement (consider against wider improvement work) where applicable
   • for certain reviews oversight will be through mortality operational group or falls panel or pressure ulcer panel
3. Develop safety actions collectively (consider against ongoing improvement work).

8.2.1.3 Action taken, path 2

1. Undertake the learning response agreed within the PSIRP (after action review, SWARM, MDT review, falls review, mortality SJR, pressure ulcer review).
2. Did the learning response identify escalation to a PSII?
   • no, go to step 4
3. Yes, the Patient Safety Investigation team undertakes PSII investigation.
4. All learning responses must be undertake using a system bested approach to:
   • gather information
   • involve those affected where possible (both staff and families or carers or patients)
   • define areas for learning and improvement (consider against wider improvement work) where applicable
   • for certain reviews oversight will be through mortality operational group or falls panel or pressure ulcer panel
5. Develop safety actions collectively (consider against ongoing improvement work).

8.2.1.4 Final outcome

1. Learning response reviewed by patient safety incident response group.
2. Monitor safety actions and learning.
3. Improvement in patient safety and patient or family experience.

8.2.1.5 No further action

1. Log event for future incident response planning indicated and continue with improvement work or risk mitigation strategies.
2. Information from the recorded event used as part of ongoing risk management or service improvement activity.

8.2.2 Learning response tools

The methods for learning from patient safety incidents have been updated, and there are now four new or adapted methods which may be used to develop learning. The table below provides a brief summary of the PSIRF learning response tools.

8.2.2.1 SWARM

The swarm huddle is designed to be initiated as soon as possible after an event and involves an MDT discussion. Staff swarm to the site to gather information about what happened and why it happened as quickly as possible and (together with insight gathered from other sources wherever possible) decide what needs to be done to reduce the risk of the same thing happening in future.

A meeting of staff which should take place as soon as possible after an incident and will involve staff involved supported by the patient safety team.

8.2.2.2 After action review (AAR)

The purpose is to gather those involved in the incident together in a safe space to look at what happened, what should have happened, why there may have been a difference, and is there any learning identified.

Takes place as soon as possible after an event. Led by the care groups and supported by Patient Safety team

8.2.2.3 Thematic analysis or MDT review

An in-depth process of review, after several similar events have occurred with input from different disciplines, to identify learning from multiple patient safety incidents, and to explore a safety theme, pathway, or process.

May be undertaken by care groups or the Patient Safety team. Triggered when a pattern or trend of incident is identified.

8.2.2.4 Patient safety incident investigation (PSII)

An in-depth review of a patient safety incident or event to understand what happened and how.

Undertaken by a trained patient safety investigator
who collates data, conducts interviews, undertakes analysis and writes the recommendations report.

The trust has a process for our response to incidents from our daily incident meetings to the monthly patient safety incident review group and reporting to the quality and safety group. This allows oversight of incident management and our PSIRF response.

The trust patient safety incident review group will have overall oversight of such processes and will challenge decision making to ensure that the trust can be assured that the true intent of PSIRF is being implemented within our organisation and we are meeting the national patient safety incident response standards.

8.3 Responding to cross-system incidents or issues

The Patient Safety team will forward those incidents identified as presenting potential for significant learning and improvement for another provider directly to that organisation’s patient safety team or equivalent. The trust will work with other providers and the relevant ICBs to maintain procedures to facilitate the free flow of information to ensure effective joint working on cross-system incidents.

The ICB will help to facilitate any incident that crosses more than one trust. These will be considered on a case-by-case basis at the monthly patient safety incident response review group where the ICB will be present giving full consideration to the potential for learning. Cross organisational reviews encourage a more cohesive and effective method of learning from incidents that are cross system. It will also include the patient or family proportionately, for example, from one source rather than multiple sources.

8.4 Timeframes for learning responses

PSIRF supports organisations to respond to incidents in a way that maximises learning and improvement.

When a PSII has been identified the review should start as soon as possible after an incident is identified, and usually completed within one to three months. PSII’s should not take longer than 6 months but this is not a new default target. If responses are taking more than 6 months, or exceeding timeframes set with those affected, then processes should be reviewed to understand how timeliness can be improved. This also applied to learning response investigations such as thematic analysis etc..

The timeframe for completing a PSII will be agreed with those affected by the incident, as part of setting the terms of reference for the PSII, provided they are willing and able to be involved in that decision.

In exceptional circumstances (for example, when a partner organisation requests an investigation is paused), a longer timeframe may be needed to respond to an incident. In this case, any extension to timescales should be agreed with those affected (including the patient, family, carer, and staff). The time needed to conduct a response must be balanced against the impact of long timescales on those affected by the incident, and the risk that for as long as findings are not described, action may not be taken to improve safety or further checks will be required to ensure the recommended actions remain relevant.

Where external bodies (or those affected by patient safety incidents) cannot provide information, to enable completion within six months or the agreed timeframe, the local response leads should work with all the information they have to complete the response to the best of their ability; it may be revisited later, should new information indicate the need for further investigative activity.

Deaths referred to the coroner will follow PSIRF guidance in relation to timeframes however if this is subject to a coroner’s Inquest it must be completed and signed off by the trust one calendar month prior to the date of the Inquest.

8.5 Safety action development and monitoring improvement

The trust acknowledges that any form of patient safety learning response (PSII or review) will allow the circumstances of an incident or set of incidents to be understood, but that this is only the beginning. To reliably reduce risk safety actions are needed which will be captured within the safety improvement plan. To achieve successful improvement safety action development will be completed in a collaborative way with a flexible approach from care groups and the Patient Safety team.

Safety improvement plans will be a mixture of approaches depending on the incident. The trust may:

• create an organisation-wide safety improvement plan summarising improvement work create individual safety improvement plans that focus on a specific service, pathway or location
• collectively review output from learning responses to single incidents when it is felt that there is sufficient understanding of the underlying, interlinked system issues
• create a safety improvement plan with the term ‘areas for improvement’ being used as well as actions
• developing areas for improvement that respond to underlying system issues will start with identifying and understanding aspects of the work system that need to change to reduce risk and potential for harm (for example, areas for improvement or system issues). Actions to reduce risk (for example, safety actions) will then be created in relation to each defined area for improvement. It will be a collaborative process Involving patients, carers and families, staff and managers where appropriate and available. This will capture valuable insights that may not otherwise be considered

8.5.1 Overview of safety action development process

1. Agree areas for improvement, specify where improvement is needed, without defining how that improvement is to be achieved.
2. Define context, agree approach to developing safety actions by defining context.
3. Define safety actions to address areas for improvement:
   • continue to involve the team, make this a collaborative process
   • focus on the system, see adapted HFIX matrix
4. Prioritise safety actions:
   • avoid prioritising action based on intuition or opinion alone
   • prioritise using the iFACES criteria and where possible test prior to implementation
5. Define safety measures:
   • identify what can be measured to determine whether the safety action is influencing what is intended
   • prioritise safety measures (consider the practicalities of measurement)
   • define measure including who is responsible for collecting, analysing, reporting and acting on the data collected
6. Write safety actions, document in a learning response report or safety improvement plan as appropriate including detail of measurement and monitoring.
7. Monitor and review, continue to be curious and monitor if safety actions are impactful and sustainable.

Safety actions will be SMART (specific, measurable, achievable, relevant, time-bound). They will also:

• be documented in a learning response report or in a safety improvement plan as applicable
• be succinct
• standalone, that is, readers should know exactly what it means without reading the report
• make it obvious why it is required (for example, given evidence in the learning response report or safety improvement plan),
  when finalising safety actions, we will continue to work with those to whom they are directed to ensure they are on board and willing to implement change

8.5.1 Safety action monitoring

Safety actions will be monitored by the Patient Safety team to ensure that any actions put in place remain impactful and sustainable. Reporting on the progress with safety actions including the outcomes of any measurements will be made to the patient safety incident review group.

8.6 Safety improvement plans

Safety improvement plans will bring together findings from various responses to patient safety incidents and issues. They can take different forms. For example, the trust might consider:

• creating an organisation-wide safety improvement plan summarising improvement work
• creating individual safety improvement plans that focus on a specific service, pathway or location
• collectively reviewing output from learning responses to single incidents when it is felt that there is sufficient understanding of the underlying, interlinked system issues
• creating a safety improvement plan to tackle broad areas for improvement (for example, overarching system issues)

The trust will consider the approach best suited to the information we have (it may be a mixture of the above). The key will be to demonstrate why a specific safety improvement plan approach is the right one based on available data, stakeholder views, improvement priorities, patient safety incident profile and insight from patient safety incident responses.

There are no thresholds for when a safety improvement plan should be developed; for example, after completing a certain number of learning responses. The decision to do so must be based on knowledge gained through the learning response process and other relevant data.

9 Oversight roles and responsibilities

An overview of organisational responsibilities in relation to PSIRF oversight, is shown below.

The trust will work with other NHS providers, the ICB, and regulators so that systems for oversight allow for improvement.

Roles and responsibilities are described in relation to our response to patient safety incidents, including investigator responsibilities and upholding national standards relating to patient safety incidents.

The principal accountability of all providers of care is to patients and service users, their families, and carers. In the fulfilment of our duty in this regard, the board has ensured that an appropriate incident management system is in place for the reporting and monitoring of incidents, including PSII’s and the recording of all never events in the annual reporting arrangements.

The executive lead for PSIRF is the executive director of nursing and allied health professionals supported by the executive medical director as the executive lead for learning from deaths.

Section 9.1 below shows an overview of organisational responsibilities.

9.1 Organisational responsibilities for an effective governance structure

9.1.1 NHS England

9.1.1.1 National

1. Support the activity of regional teams.
2. Provide strategic direction and leadership.
3. Monitor effectiveness of PSIRF.

9.1.1.2 Regional teams

1. Support ICB PSIRF leads.
2. Collaborate with NHS England commissioned services as required.
3. Support a learning system.
4. Support co-ordination of cross-system responses to patient safety incidents.
5. Identify incidents that may require centrally co-ordinated and independent PSII.

9.1.2 Integrated care board

1. Collaborate with their providers in the development, maintenance and review of provider patient safety incident response policies and plans.
2. Agree provider patient safety incident response policies and plans.
3. Oversee and support effectiveness of systems to achieve improvement following patient safety incidents.
4. Support co-ordination of cross-system learning responses.
5. Share insights and information across organisations or services to improve safety.

9.1.3 Providers of NHS-funded care

1. Ensure the organisation meets national patient safety incident response standards.
2. Ensure PSIRF is central to overarching safety governance arrangements.
3. Quality assure learning response outputs.

9.1.4 Care Quality Commission

Assess systems’ and organisations’ ability to respond effectively to patient safety incidents, including whether change and improvement follow its response to patient safety incidents.

9.2 RDaSH oversight and responsibility

9.2.1 The board

The board is responsible for:

• ensuring robust incident reporting, learning and improvement systems are in place and that these are monitored and reviewed and compliant with external regulation
• ensuring that patient safety incidents are reviewed, and learning actions and improvement plans are implemented
• ensuring that data in relation to patient safety incident reports is analysed to identify themes and trends and appropriate improvements are undertaken

9.2.2 Executive director of nursing and allied health professionals or executive medical director

The executive director of nursing and allied health professionals is the accountable officer for patient safety, the patient safety incident response framework and the accompanying policy and plan. The executive director of nursing and allied health professionals is supported by the executive medical director as the accountable officer for learning from deaths.

9.2.3 Quality and safety group

The quality and safety group is responsible for overseeing that robust incident management processes are in place. The committee is also responsible for receiving assurance from patient safety incident review group that learning actions and improvement plans following patient safety incidents are effectively monitored and implemented.

9.2.4 The patient safety incident review group

The patient safety incident response group has responsibility for coordinating, overseeing and monitoring learning responses for patient safety incidents.

The patient safety incident review group will provide assurance that the patient safety incident response policy and plan is effectively implemented across the trust, that all care groups have systems in place to ensure all patient safety incidents are reported. That learning occurs at team and care group level and ensure that that the learning actions and improvement plans following learning responses are implemented, monitored and that learning is shared across the organisation.

9.2.5 Mortality surveillance group

The mortality surveillance group is responsible for the oversight of all deaths reported as incidents and sharing learning from the structured judgement review (SJR) process in line with the trust’s learning from deaths policy the right thing to do.

9.2.6 Director of human resources

The director of human resources is responsible for:

• ensuring that support for staff following incidents is available via the workplace wellbeing service
• ensuring occupational health guidance, advice and service is available for staff following incidents
• ensuring that media communications, in relation to incidents, are managed effectively through the communications manager

9.2.7 Care group directors of nursing and associate medical directors

Care group directors of nursing and associate medical directors are responsible for ensuring that their staff comply with the requirements set out in this policy. This will be achieved through:

• ensuring that all incidents or accidents are reported and managed in accordance with this policy
• ensuring that all staff, including temporary staff, are aware of this policy and their duties with regard to incidents or accidents
• ensuring all incidents or accident reports and learning actions and improvement plans relating to their directorate are reviewed at the appropriate team or directorate level to support learning, the reduction of risk and the prevention of recurrence
• ensuring all risks identified following the investigation of an incident or accident relating to their directorate are recorded on the appropriate electronic risk register and reviewed and updated as required
• ensuring that incidents or accidents learning actions and improvement plans relating to other directorate or services are communicated effectively within their services, ensuring any identified risks are recorded on the appropriate electronic risk register and reviewed and updated as required
• reviewing the data derived from incident reports to identify any themes or trends for their sphere of responsibility, and taking appropriate action as needed
• sharing full reports including learning actions and improvement plans through their directorate and team governance framework
• ensuring staff, patients, families and carers or others involved in incidents are kept informed and receive support as appropriate in line with the requirements of the statutory duty of candour and this policy
• ensuring all staff in their directorate receive training at induction and subsequently as required by this policy

9.2.8 Accountable officer for controlled drugs

Sharing information within local intelligence networks (LIN) in relation to controlled drug incidents and, or fraudulent behaviour of relevant people: in this context a relevant person is anyone who prescribes, dispenses, administers or transports drugs and information will only be shared about those individuals where there are well founded concerns in relation to patient safety. This is in-line with the Statutory Instrument 3148 of the Health Bill in relation to the accountable officers responsibilities.

9.2.9 Specialist advisors

Specialist advisors are staff with particular areas of knowledge and specialist expertise who are available to support staff in implementing this policy. They include the patient safety specialists, patient safety partners, the Health and Safety Risk team, medicines safety officer, information governance officer, the senior nurse for infection prevention and control, local security management service advisor and fire officer and the safeguarding adults and children nurse consultant (this is not an exhaustive list).

9.2.10 The Patient Safety team

• Act as custodians for the patient safety incident response policy and Plan and support the monitoring processes in relation to compliance and implementation of learning actions and improvement plans.
• Provide advice and support to all staff and ensure training, resources and information is available to enable the effective reporting, investigation and management of incidents.
• Report externally in partnership with the Health and Safety team, to the health and safety executive (RIDDOR), Care Quality Commission, ICB, NHS England or NHS Improvement and other agencies as required.
• Maintain the Ulysses database for incidents, learning actions and improvement plans.
• Keep all accident or incident or investigation information in line with trusts records retention requirements set out within the records management policy.
• Provide a quality assurance review of all incidents reported.
• Review investigation reports for patient safety incidents against standards set by the patient safety incident response plan.
• Prepare overviews of patient safety incident reports for the quality and safety group and any other identified committees.
• Provide a whole range of reports to different levels within the organisation to enable scrutiny of data, identification of risks and the sharing of learning from all incidents.

9.2.11 Patient safety incident investigators

Are responsible for carrying out thorough investigations and supporting or carrying out learning responses into the incidents they are nominated to complete or oversee, in accordance with the terms of reference set and using approved investigation techniques.

9.2.12 Managers

Under section 7 of the Health and Safety at Work Act 1974, managers for an area are responsible for ensuring incidents are appropriately managed, investigated, acted upon and lessons are learnt.

Managers are also responsible for supporting staff following a traumatic incident and ensuring that service users and carers or others involved in incidents are kept informed and receive support as appropriate in line with the requirements of the statutory duty of candour and this policy.

9.2.13 All staff

All staff have a duty of care to provide safe services and do no harm, to be responsible for keeping themselves and others safe and are expected to report incidents as part of their general duties under section 7 of the Health and Safety at Work Act 1974.

All staff members are expected to notice accidents, incidents and near misses and report and manage them in accordance with this policy.

10 Complaints and appeals

This section should be read alongside the listening and responding to concerns and complaints policy (formally complaints handling policy).

The trust is committed to dealing with any complaints that may arise as quickly and as effectively as possible as set out in the Local Authority Social Services and National Health Service Complaints (England) Regulations 2009. In line with the processes set out in the patient safety incident response framework. Patients their families or carers and staff will be supported to be able to input into learning responses, patient safety incident investigations and in the development of safety actions.

However, patients their families or carers may wish to complain. The reviewers and investigators of the patient safety incidents will ensure that patients and their families or carers have the required information in order to complain and will support if agreed to escalate to the Complaints team.

Patients and their family can raise a complaint via RDASH patient advice and liaison service (PALS) at:

• Telephone: 800 015 4334
• Email: rdash.pals@nhs.net

RDASH complaints are available during normal office hours, Monday to Friday (excluding public bank holidays) at:

• Telephone: 07967 793306
• Email: rdash.complaints@nhs.net

Staff members can raise concerns by contacting the freedom to speak up guardian at:

• Telephone: 07836 680975
• Email: rdash.ftsu@nhs.net

11 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

11.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.

Consequently, the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity, and respect, (when appropriate this should also include how same sex accommodation is provided)

11.1.1 How this will be met

No issues have been identified in relation to this policy.

11.2 Mental Capacity Act

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

11.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

12 Appendices

12.1 Appendix A Patient safety incident response plan

12.1.1 Introduction

This patient safety incident response plan sets out how Rotherham, Doncaster and South Humber NHS Foundation Trust (RDaSH) intends to respond to patient safety incidents over a period of 12 to 18 months.

It sets out the main work streams which has been decided upon following internal and external stakeholder engagement and quantitative data review.

The plan is not a permanent rule that cannot be changed. It will remain flexible and consider the specific circumstances in which patient safety issues and incidents occurred and the needs of those affected.

The trust will review patient safety information regularly through governance and safety meetings, providing updates to the work streams within plan.

The whole plan will be reviewed every 12 months to ensure the work streams fully reflect the patient safety issues with the greatest potential for learning and improvement.

12.1.2 Our services

RDaSH is registered with the Care Quality Commission to provide the following services to our communities:

• adult mental health services
• older peoples mental health services
• NHS Talking Therapies
• drug and alcohol services for adults (Doncaster)
• forensic services (Doncaster)
• adult physical health community services
• St Johns Hospice
• learning disability services
• children and young peoples mental health services
• children young people and families

More information about our trust and the services we provide can be found on our trust website service page.

12.1.3 Defining our patient safety incident profile

The following stakeholders were involved in identifying, analysing, and defining RDaSH’s patient safety incident profile:

• staff, through incidents reported on the trust’s incident reporting system and the staff incident reporting survey
• patients and carers, through review of the thematic contents of complaints and concerns
• specialist advisors and leads for organisational data in the trust

The trust’s patient safety incident profile was developed through review and analysis of the following organisational data:

• incidents reported 2021 to 2022, 2022 to 2023 and 2022 to 2023
• complaints
• PALS
• serious incidents
• freedom to speak up reports
• human resources
• clinical negligence claims
• inquests
• key themes identified from the quality and safety group and supporting subgroups
• data from quality surveillance processes:
  • falls
  • tissue viability
  • mortality

The trusts PIRSP includes the patient safety incidents identified through analysis of the organisational data that present the greatest opportunities for learning and subsequently improving the safety and quality of care our patients receive.

The trust has used the criteria below when defining our patient safety incident responses:

• potential for significant harm or of significant psychological harm to patients
• potential for significant harm or of significant psychological harm to staff
• potential loss of trust in RDaSH services
• impact on quality and delivery of RDaSH services
• likelihood of occurrence including persistency of the risk, frequency and potential to escalate.

12.1.3.1 Patient safety priorities

• Claims.
• Complaints.
• Serious incident investigations.
• Incidents.
• Freedom to speak up.

12.1.4 Our patient safety incident response plan, national requirements

Some events in healthcare require a specific type of response as set out in national policies or regulations. These responses may include review by or referral to another body or team, depending on the nature of the event. The table 1 sets out the local or national mandated requirements that are applicable to RDASH and the patient safety response that will be undertaken in these circumstances.

The trust will respond to recommendations and safety actions from the learning responses identified below, both internal and from external agencies or organisations as required and feed safety actions into the trust quality improvement processes.

Table 1 National requirements for patient safety incident response

National priority patient safety incident types	Required response
Incidents meeting the never events criteria 2018, or its replacement	PSII locally led by RDASH Patient Safety and Investigations team
Deaths thought more likely than not due to problems in care (incidents meeting the learning from deaths criteria for PSII)	PSII locally led by RDASH Patient safety and investigations team
Deaths of patients detained under the Mental Health Act (1983), or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care	PSII
Mental health-related homicides	Referral to the NHS England Regional Independent Investigation team (RIIT) for consideration of an independent PSII. Locally-led PSII may be required
Deaths under the state or in custody (for example, police custody, in prison, etc) where health provision is delivered by the NHS	Any death in prison or police custody will be referred (by the relevant organisation) to the prison and probation ombudsman (PPO) or the independent office for police conduct (IOPC) to carry out the relevant investigations healthcare organisations must fully support these investigations where required to do so
Deaths of persons with learning disabilities	Learning disability mortality structure judgement review in line with RDaSH learning from deaths policy. LeDeR referral process
Child death	Child death overview process locally-led PSII (or other response) may be required alongside the panel review, organisations should liaise with the panel
Domestic Homicide (DH)	A domestic homicide is identified by the police usually in partnership with the community safety partnership (CSP) with whom the overall responsibility lies for establishing a review of the case. Where the CSP considers that the criteria for a domestic homicide review (DHR) are met, it uses local contacts and requests the establishment of a DHR panel The Domestic Violence, Crime and Victims Act 2004 sets out the statutory obligations and requirements of organisations and commissioners of health services in relation to DHRs
Safeguarding incidents in which babies, children, or young people are on a child protection plan; looked after plan or a victim of wilful neglect or domestic abuse or violence. Adults (over 18 years old) are in receipt of care and support needs from their local authority. The incident relates to FGM, Prevent (radicalisation to terrorism), modern slavery and human trafficking or domestic abuse or violence	To be referred to RDASH Safeguarding team. Healthcare organisations must contribute towards domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any other safeguarding reviews (and inquiries) as required to do so by the local safeguarding partnership (for children) and local safeguarding adults boards

12.1.5 Our patient safety incident response plan, local focus

12.1.5.1 Locally agreed patient safety event priorities and learning responses

PSIRF allows organisations to explore patient safety events relevant to their context and the populations served. Through our analysis of our patient safety data, we have identified nine patient safety event types as priorities for the trust. RDASH considers all of the patient safety event types set out in Table 2 below to be key to delivering high-quality, person-centred care. We will apply a systems-based approach to learning from these patient safety events.

The outcomes and safety actions of the PSIIs will be used to inform our patient safety improvement planning.

Learning identified from the PSII and agreed learning response tools will be shared through the trust organisational leaning forum, the care group organisational learning forums, and the monthly clinical learning brief.

Table 2 Locally agreed patient safety event priorities and learning responses

Patient safety event type or issue	Planned response
Suspected suicide in inpatients	PSII
Suspected suicide in crisis, home treatment and liaison services	PSII
Unexpected inpatient death	SWARM huddle to be completed next working day. Where there are concerns of lapses in care identified through the mortality operational group process, a PSII will be completed by the patient safety and investigation team. Where a lapse in case has not initially been identified but red flags are present, a mortality SJR will be completed by the mortality SJR reviewer. The SJR reviewer will have the opportunity to escalate to MOG at any point if a lapse in care is identified and that a PSII is required. This is in line with the National learning from deaths policy
All other suspected suicide or unexpected death (not meeting the criteria of point 1 and 2 above)	All suspected suicides and unexpected deaths are reviewed weekly at the mortality operational group. Where there are concerns of lapses in care identified, either through the mortality operational group process, or through the medical examiner’s office, a PSII will be completed by the patient safety and investigation team. Where a lapse in care has not initially been identified, a records review or mortality SJR will be completed. The reviewer will escalate to MOG at any point. that a PSII is indicated due to potential lapses in care or significant complexity. This is in line with the national learning from deaths policy
Any area or service that has been identified as a concern by HM coroner	PSII
An emerging theme or risk identified by the care groups or via the daily incident meeting (see below for further information regarding the daily incident meeting)	To agree locally if the event(s) would benefit from a PSII or Thematic analysis. To be led by the Patient Safety and Investigations team
Trust acquired pressure ulcers graded category 3 or above	Pressure ulcers review paperwork to be completed and reviewed at the Pressure Ulcer panel. The pressure ulcer panel will escalate cases for consideration of a full PSII investigation if there is a suspected problem in care or multiple avenues of learning. The PSII will be completed by the Patient Safety and Investigations team
Inpatient falls rated as moderate or above	Falls review paperwork to be completed by the local team and reviewed at the trust Falls panel. The falls panel will have the opportunity to escalate cases for consideration of a full PSII investigation where there is a suspected problem in care or multiple avenues of learning. The PSII will be completed by the Patient Safety and Investigations team
Complaints where the trust has significant concerns or lapses in care identified	The patient safety and investigation team will review each case individually to agree on the appropriate learning response tool, PSII, thematic analysis, SWARM, MDT review
Any other patient safety events resulting in major or catastrophic harm, including psychological or physical harm to our staff or patients (this excludes any incident type specifically listed in the plan)	To be discussed with the patient safety team to consider a PSII or appropriate learning response
Any other patient safety event meeting the requirements for duty of candour (this excludes any incident type specifically listed in the plan)	Appropriate learning response tool to be agreed and led on locally within the service or care group. After action review, SWARM, MDT review, thematic analysis

12.1.5.2 Other incidents

All incidents are discussed at the trusts daily incident meeting. The daily incident meeting is open to all staff across the trust. All incidents reported the previous day are discussed. The members of the daily incident meeting may identify incidents not listed above that they feel require a learning response, this will be monitored by the patient safety and investigation team and recurring themes will be added to the patient safety incident response plan as appropriate.

The trust encourages the use of the learning response tools recommended through PSIRF, these are After Action Reviews, SWARM huddles and MDT reviews. We have developed a page on the intranet to provide further information on the use of these tools, along with the RDASH template and the NHS England guides for each tool. The intranet page also includes information on system-based approaches to learning and a link to training courses provided by HSIB.

Other incidents

Patient safety event type or issue	Planned response
Incidents in screening programmes	Reported to Public Health England (PHE). To agree locally if the event(s) would benefit from a PSII, after action review or thematic analysis. To be led by the care group and supported by the Patient Safety and Investigations team
Infection prevention control (IPC)	To agree locally if the event(s) would benefit from a PSII, after action review or thematic analysis. To be led by the IPC team and supported by the Patient Safety and Investigations team

12.1.6 Incident responses

PSII is not the only tool we will use to respond to incidents. Our policy framework will describe other ways staff can respond to incidents. This will detail both how to respond to incidents thematically, but also how to respond to individual incidents.

We have outlined several ways we can respond to individual incidents, including:

Incident responses

Response	Response details
Safety Huddle	A planned team gathering to regroup, seek advice, talk about the day or triggered by an event to assess what can be learned
SWARM Huddle	Pulls everyone together to support and identify any immediate learning
After Action Review (AAR)	A structured gathering those involved in the incident together in a safe space to look at what happened, what should have happened, why there may have been a difference, and is there any learning. This should be carried soon after the event and have the right people there. It may lead to a wider meeting
MDT or thematic review	Input from different disciplines, analysing a patient safety theme or perceived pattern to identify issues and learning from multiple patient safety incidents
PSII	Full review

12.1.7 Timeframes for investigations

Timeframes for investigations

Patient safety event type or issue	Timeframes
Patient safety event or death not referred to the coroner	To be agree with the family and dependant on complexity
Deaths referred to coroner	This will follow PSIRF guidance in relation to timeframes agreed with the person or family however if this is subject to a coroner’s Inquest it must be completed and signed off by the trust one calendar month prior to the date of the Inquest

12.1.8 Reporting

Patient safety incidents that fall into the category of PSII’s will be reported on the national reporting system and will adhere to national guidance.

12.1.9 Core governance

The trust has a process for our response to incidents from our daily incident meetings to the monthly patient safety incident review group and reporting to the safety and quality group. This allows oversight of incident management and our PSIRF response.

The trust patient safety incident review group will have overall oversight of such processes and will challenge decision making to ensure that the trust can be assured that the true intent of PSIRF is being implemented within our organisation and we are meeting the national patient safety incident response standards.

The Integrated care board (ICB) representatives will be part of the core membership of the monthly patient safety incident review group.

12.2 Appendix B Glossary of terms

 

Definitions

Term	Definition
Patient safety incident reporting framework (PSIRF)	Sets out the NHS’s approach to responding to patient safety incidents
Patient safety incident reporting plan (PSIRP)	Trust specific It describes what is being done
Systems engineering initiative for patient safety (SEIPS)	A framework for understanding inter-relationships across the structures, processes and outcomes
Root cause analysis (RCA)	The process of examining what happened in order to establish how and why an adverse event occurred
National reporting and learning system (NRLS)	A central database of patient safety incident reports
Learning from patient safety events (LFPSE)	LFPSE is replacing the current strategic executive information system (StEIS), to offer better support for staff from all health and care sectors
Patient safety partner (PSP)	Relates to the role that other lay people can play in patient safety
Serious incident framework (SIF)	Framework to manage reporting of serious incidents. Is being replaced by PSIRF
Human factors	A scientific discipline that seeks to understand the interactions between humans and the elements of systems
Systems thinking	A mindset of ensuring that an investigation explores the multiple interacting contributory factors across the care system
Never events	Patient safety incidents that can cause harm (or have the potential to do so) and are wholly preventable
Incident response tool	The agreed tool used to review or investigate
After action review (AAR)	An incident response tool
Thematic analysis (TR)	The process of examining in order to identify common themes
Structured judgement review (SJR)	A tool used in the review of deaths
Investigative interviewing	Conversation understanding of the how and why something occurred
Healthcare Safety Investigation Branch (HSIB)	National patient safety body
Situation background assessment recommendation (SBAR)	Consists of standardised prompt questions in four sections to ensure that staff are sharing concise and focused information
NHS Standard Contract	A commissioning process
Safety Culture	Continuous learning and improvement of safety risks
Psychological safety	A shared understanding that you can speak up with ideas, questions or concerns, without fear of embarrassment or humiliation
Just Culture (JC)	Considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution
NHS patient safety strategy	Strategy for how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems
Duty of candour (D of C),	A regulatory requirement for care providers to be open and transparent with service users where things have gone wrong
Caldicott guardian	Senior person responsible for protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing
Freedom to speak up guardian (FTSU)	Supports workers to speak up when they feel that they are unable to do so by other routes

 

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Document control

• Version: 1.
• Unique reference number: 1074.
• Approved by: Board of directors.
• Date approved: 23 November 2023.
• Name of originator or author: Deputy director organisational learning, patient safety and inquests.
• Name of responsible individual: Executive director of nursing and allied health professionals and deputy chief executive.
• Date issued: 9 February 2024.
• Review date: 28 February 2026.
• Target audience: Trust wide.

Page last reviewed: May 07, 2024
Next review due: May 07, 2025

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