Patient safety incident response framework

Cornwall Partnership NHS Foundation Trust as an early adopter of the patient safety incident response framework (PSIRF) has developed alongside key stakeholders a patient safety incident response plan (PSIRP) which sets out how we will respond to patient safety incidents reported by staff and patients, their families and carers as part of work to continually improve the quality and safety of the care provided. The plan sets out the ways the Trust intends to respond to patient safety incidents to learn and improve through patient safety incident investigations (PSIIs) and patient safety reviews (PSRs).

The Trust has identified the following events that we intend to investigate selected cases through a PSII:

  • self-harm incidents for patients under 25 years of age and receiving support from community mental health services
  • unwitnessed falls for patients over 80 years of age admitted to our adult inpatient wards
  • category 2 or unstageable pressure ulcers developed in the community while receiving care from both district nurses and another care provider  
  • delay in initial start of treatment following referral for children and adolescent mental health service (CAMHS) with moderate or severe mental health conditions
  • interruption in continuity of community nursing care where the team was unable to provide treatment or support as planned or expected
  • complications in transition of care for a young person with a moderate or severe mental health diagnosis transitioning from CAMHS to adult mental health services

Resource for a few additional PSIIs has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.                                    

We would also undertake a number of PSII’s on national priorities which include:

  • never events
  • incidents that meet the learning from deaths criteria
  • death or long-term severe injury of a person detained under the Mental Health Act
  • domestic homicide

Deaths that had previously been investigated as serious incidents under the 2015 framework will be reviewed in line with the learning from deaths national priority, during the review process certain incidents may proceed as a PSII.

In the years ahead, the trust will seek data and insight from stakeholders to inform potential future categories for local patient safety incident investigation and system improvement.

Responding to patient safety incidents patient story videos

NHS England have produced a series of patient story videos to be used as training resources for NHS organisations to demonstrate the impact the initial response to a patient safety incident and subsequent investigation has on the patient

Kathryn’s story

Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed.

Kirsty’s story

Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip.

Valerie’s story

Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication.