The Patient Safety Incident Response Framework sets out the approach to responding to patient safety events for the purpose of learning and improvement in England. The PSIRF, published in August 2022, will replace the Serious Incident Framework as of 1 April 2024 for all healthcare organisations operating under the NHS standard Contract. Although PSIRF does not affect the statutory requirement for child death reviews it does affect the Serious Incident process that ran alongside the review in important ways:

  • The term ‘serious incident’ and its associated threshold for prompting a serious incident investigation as defined in the Serious Incident Framework is retired under PSIRF.
  • PSIRF makes no distinction between ‘patient safety incidents’ and ‘serious incidents’ – organisations will no longer be required to categorise or ‘declare’ safety events as ‘serious incidents’.
  • PSIRF promotes a proportionate approach to responding to safety events focused on the potential for learning and improvement rather than thresholds of harm or seriousness.

What does this mean for the child death review process?

  • Responses to safety events will look different – organisations will be using a new template and new methods.
  • Learning responses focus on system learning and improvement and will not make judgements about causality and avoidability.
  • The 60-day requirement for completion of a learning response has been removed – timeframes should now be set in agreement with those affected by the event (including patients, families and staff) to enable them to meaningfully contribute to the response.

What can child death reviewers do?

  • Liaise with the patient safety team to understand their approach to responding to child deaths. This should also be documented in their patient safety incident response plan, which will be published on the organisation’s external website.
  • Find out more about PSIRF by visiting the NHS England website: NHS England » Patient Safety Incident Response Framework

Back to: Home | Other guidance