Other helpful resources
Policies and related processes
Given the changing landscape of patient safety policy and related processes, it may be useful to familiarise yourself with the information below:
NHS England » Guide to engaging and involving patients, families and staff following a patient safety incident
Published alongside the Patient Safety Incident Response Framework (PSIRF), the ‘Guide to engaging and involving patients, families and staff following a patient safety incident’ sets out expectations for how those affected by an incident should be treated with compassion and involved in any investigation process. The guide has been produced by NHS England in partnership with the Healthcare Safety Investigation Branch and Learn Together. You can also listen to this podcast to discuss how it was developed.
NHS England » The Patient Safety Incident Response Framework (PSIRF)
The NHS England Patient Safety Incident Response Framework (PSIRF) is written to guide all NHS Trusts nationally across England in how to identify and respond to patient safety incidents. This includes Patient Safety Incident Investigations (PSII), but also other response types.
Duty of Candour
The Department of Health and Social Care mandates that each NHS Trust makes patients or their family aware that a patient safety incident has taken place via Duty of Candour. This 8-minute animation and this guidance from the Nursing and Midwifery Council offers more information on how Duty of Candour can be fulfilled effectively. Peter Walsh also sums up what progress has been made since the introduction of Duty of Candour in this blog.
Parliamentary and Health Service Ombudsman (PHSO)
The Parliamentary and Health Service Ombudsman respond to unresolved complaints. They can support you if you have made a complaint following your incident and the organisation has not responded to your complaint or you are dissatisfied with their response.
NHS England » Learning from Deaths
The learning from deaths national guidance is for NHS trusts on working with bereaved families and carers. It advises trusts on how they should support, communicate and engage with families following a death of someone in their care.
Guide to Coroner Services
This guide provides bereaved people with an explanation of the coroner investigation and inquest process as well as links to other organisations that may also provide help and advice. The guide aims to ensure that the department recognises the need for bereaved people to be involved throughout the inquest process.
NHS England » Patient Safety Strategy
This website contains information about what patient safety is and how the Patient Safety Strategy aims to minimise patient harm. The Patient Safety Strategy sets out how the NHS aims to support staff and providers to share safety insight and empower people (patients and staff) with the skills, confidence and tools to improve safety.
NHS England » Framework for Involving Patients in Patient Safety
The NHS Patient Safety Strategy (July 2019) recognises the importance of involving patients, their families and carers and other lay people in improving the safety of NHS care, as well as the role that patients and carers can have as partners in their own safety. This framework sets out how NHS organisations should involve patients in patient safety.
NHS England » Integrated Care Boards (ICB)
Integrated care boards (ICBs) commission most of the hospital and community NHS services in the local areas for which they are responsible. You can raise a complaint with your local ICB. Find contact details for your local ICB on the NHS website.
The NHS Constitution for England
This Constitution establishes the principles and values of the NHS in England. It sets out rights to which patients, public and staff are entitled, and pledges which the NHS is committed to achieve, together with responsibilities, which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively. This document was most recently updated in 2021.
Care Quality Commission (CQC)
The CQC are the independent regulator of health and social care in England. They make sure health and social care services provide people with safe, effective, compassionate, high-quality care and the encourage care services to improve. They monitor, inspect and regulate services and publish what they find.
Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK)
‘MBRRACE-UK’ is the collaboration appointed by the Healthcare Quality Improvement Partnership (HQIP) to run the national Maternal, Newborn and Infant clinical Outcome Review Programme (MNI-CORP) which continues the national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths. The aim of the MNI-CORP MBRRACE-UK programme is to provide robust national information to support the delivery of safe, equitable, high quality, patient-centred maternal, newborn and infant health services.
The Nursing and Midwifery Council
The Nursing and Midwifery Council are the independent regulator for nurses and midwives in the UK, and nursing associates in England. Their vision is safe, effective and kind nursing and midwifery practice that improves everyone’s health and wellbeing.
The General Medical Council
The GMC work to protect patient safety and improve medical education and practice across the UK.
NICE Guidelines
NICE produced evidence-based recommendations developed by independent committees, including professionals and lay members, and consulted on by stakeholders.
FutureNHS Collaboration Platform
FutureNHS is a collaboration platform that empowers everyone working in health and social care to safely connect, share and learn across boundaries. Join the Patient Safety Incident Response Framework (PSIRF) workspace to access additional relevant information.
Training
It is highly recommended that engagement leads attend training to consolidate their learning. The Patient Safety Incident Response Framework (PSIRF) suggests that staff should attend at least 6 hours of training as a minimum requirement.
Healthcare Safety Investigation Branch (HSIB)
This website contains links to free online courses for NHS staff with a focus on those with patient safety and investigation roles. Examples of courses include ‘A systems approach to learning from patient safety incidents’. There are also a number of courses designed to support NHS trusts to implement and use the PSIRF.
Baby Lifeline
Baby Lifeline delivers high-quality, multi-professional training for the maternity sector; encouraging best clinical practice and communication to improve outcomes for pregnant women, their unborn and new-born babies. Their focus for the last 20 years has been to develop training which relates and directly responds to the critical factors causing avoidable tragedies in maternity. This website sign-posts staff to training courses.
Making Families Count
Making Families Count run powerful, hard-hitting and inspirational training for health and care providers, the voluntary sector and public organisations in the UK. The training aims to enable care providers to respond effectively and compassionately to patients and families when things go wrong. The website contains links to different types of training.
Action Against Medical Accidents (AvMa)
AvMA offer training such as the ‘Implementing the Duty of Candour with Empathy’ training day. This covers the must do’s and the grey areas around the statutory Duty of Candour, with a strong emphasis on going beyond mere compliance and delivering the duty of candour in a meaningful way for patients and families, and for the staff involved and the organisation.
Being Human in Healthcare
Being Human in Healthcare is ran by healthcare professionals and educators who understand the need to adapt aviation style Human Factors knowledge and techniques, to make them more relevant and applicable to the highly complex and variable world of health and social care. They deliver a range of courses including PSIRF and human factors specific courses.
ConsequenceUK
Consequence UK Ltd works with NHS organisations, private healthcare providers, and social care organisations to enable effective learning from patient safety and safeguarding incidents and to deliver meaningful and measurable change.
Facere Melius Patient Safety Training
Facere Melius training courses provide a safe space to discuss and debate the challenges of implementing the PSIRF framework as well as providing delegates with example tools, techniques and policies that can be used and adopted locally.
InPractice Training
InPractice host training sessions, including a virtual one-day session which provides delegates with the expertise in involving patients, families, carers and staff in patient safety incident investigations.
MedLed Training
The MedLed learning journeys take a Systems Approach to investigations and helps you to meet the requirements of the NHS PSIRF. Programmes have been piloted and co-developed with a PSIRF early adopter site to ensure that it fully meets the needs of NHS professionals and fulfils the framework.
Morgan Human Systems Ltd
Morgan Human Systems Ltd offers a range of training, including a course to support the development of expertise in engaging and involving patients, families, carers, and staff affected by patient safety incidents, in line with NHS guidance, based upon national and internationally recognised good practice.
NHS Professionals Academy
To support Trusts and Integrated Care Systems implement the PSIRF, NHS Professionals offer courses designed to equip staff with the essential skills and behaviours needed to investigate incidents and coach leaders on ways to develop positive safety cultures across their organisations.
OxSTaR
OxSTaR offer a range of courses on human factors/ergonomics and improvement science. These are tailored to the audience and can be offered across a half day, day or two days. Courses generally consist of a mix of teaching, case studies and practical workshops.
Systemic Factors Limited
Systemic Factors Limited specialises in both support and training in human factors and safety investigation in high reliability industries, and offer a variety of patient safety courses. This includes an interactive one-day workshop focusing on compassionate engagement with those affected by patient safety incidents.
Useful information and support for patients and families
Patient Advice and Liaison Service (PALS)
PALS can be found in each NHS Trust. You can talk to a PALS member of staff about your incident and they will try to help you resolve any issues with the Trust informally. PALS can be particularly useful if you need action immediately, for example if the incident has been a problem with your care and you are still in hospital. You can ask a member of staff at the Trust for details of the local PALS service, or you can find more information using the link above.
Action Against Medical Accidents (AvMA)
AvMA is an independent charity which provides free specialist advice to people who have been affected by patient safety incidents. They can advise you about your investigation as well as other processes that you may be faced with or be considering (for example inquests; complaints; fitness to practice/regulatory issues raised by the incident; or legal action). They can also give you details of other organisations providing different sorts of support.
The Patients Association
An independent patient charity campaigning for improvements in health and social care for patients. You can call the helpline on 0800 345 7115 (freephone number), or email helpline@patients-association.org.uk.
Citizens Advice
Citizens Advice can provide high quality, independent advice about any problems or questions you might have. They also have a network of national and local independent charities that can provide free and confidential advice.
Healthwatch
Healthwatch is your health and social care champion where you can share your experience. As an independent statutory body, they have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care. Last year they helped nearly a million people have their say and get the information and advice they need.
Care Opinion
A place where you can share your experience of health or care services, and help make them better for everyone.
Mind
A registered charity that provides support and advice to anyone who is struggling with their mental health. If you have been affected emotionally following the incident you experienced or if you are finding the investigation process difficult, you can contact Mind.
Samaritans
A registered charity providing support to anyone in emotional distress or anyone who is struggling to cope. You can contact the Samaritans for free and there will always be someone there to listen to you and talk to you. Their support is available 24 hours a day, 7 days a week, 365 days of the year.
The Harmed Patients Alliance
A campaign group founded by Joanne Hughes and James Titcombe, two parents who have lost children due to unsafe healthcare. Harmed Patients Alliance works to raise awareness of harmed patients and families needs for recovery, and call for the elimination of poor responses and secondary harm.
Making Families Count
Making Families Count aims to improve outcomes for families affected by serious harm and traumatic bereavements in health and social care services. Making Families Count is made up of people who are recognised experts in their respective fields. Some have suffered the loss of a family member through traumatic and complex bereavement. Others are highly experienced, senior NHS investigators.
Safety investigation jargon buster > HSIB
Visit the HSIB website to view a guide to the terms commonly used in safety investigations and their definitions.
Get help with funeral costs
Find out if you could get a Funeral Expenses Payment (also called a Funeral Payment) if you need help to pay for a funeral you’re arranging.
What to do when someone dies
Check what to do after a death – how to register the death, notify government departments and deal with the estate.
Tell Us Once
A service that lets you report a death to most government organisations in one go.
VoiceAbility Advocacy and Involvement
VoiceAbility offers a free and independent advocacy and user involvement service to support people who face disadvantage or discrimination. They support people to speak up and have their rights and choices respected.
POhWER
POhWER help people who, because of disability, illness, social exclusion and other challenges, find it difficult to express their views or get the support they need. Their mission is to empower people to have a voice and make a real difference to their lives. They do this by speaking for them when they can’t and supporting them to speak for themselves when they can.
INQUEST
INQUEST is a small charity that provides free advice to people bereaved by a death in custody and detention and is entirely independent of government. The charity provides specialist advice on deaths in custody or detention, or involving state failures in England and Wales. This includes a death that has occurred in psychiatric care and cases that involve multi-agency failings and raise wider issues of state and corporate accountability.
WAY Widowed & Young Bereavement Support UK
Widowed and Young (WAY) offers a unique peer-to-peer support network to anyone whose partner died when they were young.
Winston’s Wish
Winston’s Wish charity supports bereaved children, young people, their families and the professionals who support them.
Papyrus UK Suicide Prevention
PAPYRUS Prevention of Young Suicide is the UK charity dedicated to the prevention of suicide and the promotion of positive mental health and emotional wellbeing in young people.
Survivors of Bereavement by Suicide (SOBS)
SOBS are the only UK-based organisation offering peer-led support to adults impacted by suicide loss.
Cruse Bereavement Support
Helping people through one of the most painful times in life – with bereavement support, information and campaigning.
HundredFamilies
HundredFamilies provides information, analysis and support for families affected by mental health homicides in Britain.
Grief Encounters
A peer support group for LGBTQ people who have experienced a bereavement.
Jewish Bereavement Counselling Service (JBCS)
JBCS support the Jewish community following a bereavement.
Muslim Community Helpline
Confidential, non-judgmental listening and emotional support service for people from the Muslim community.
Muslim Bereavement Support Service
Volunteers provide guidance in accordance with the Qur’an and Ahadeeth on bereavement, with advice on prayers and other religious aspects.
Campaign for Safer Births
The Campaign for Safer Births is working to improve NHS maternity services in order to reduce the avoidable deaths and injuries of babies and mothers during labour.
Birth Trauma Association
Helping people traumatised by childbirth and campaigning for improvements
The Lullaby Trust
The Lullaby Trust offers confidential support to anyone affected by the sudden and unexpected death of a baby or young child.
Saving babies’ lives. Supporting bereaved families (SANDS)
Sands supports anyone who has been affected by the death of a baby before, during or shortly after birth.
The Compassionate Friends
The Compassionate Friends (TCF) is a charitable organisation of bereaved parents, siblings and grandparents dedicated to the support and care of other similarly bereaved family members who have suffered the death of a child or children from a month old and and from any cause.
Petals Charity
Petals provide and promote specialist counselling for parents across the UK following baby loss.
Tommy’s
Tommy’s exists to support, care for and champion people, no matter where they may be on their pregnancy journey.
The Motherhood Group
Sandra Igwe is a Black maternal health advocate, TEDx speaker, and the Founder of The Motherhood Group, a social enterprise that supports the Black maternal experience. The group was founded by Sandra Igwe in 2016, after the traumatic birth of her first daughter, Zoe Igwe.
FIVEXMORE
Five X More is a grassroots organisation committed to changing Black women and birthing people’s maternal health outcomes in the UK. It was initiated in 2019 when two Black mothers came together with the dream of improving maternal mortality rates and health care outcomes for Black women.
Useful information and support for staff
Staff Support Guide – Patient Safety Learning
Whilst the first priority of any avoidable harm will be to support patients and their families, staff directly and indirectly involved should also be provided with the support they need following an incident and subsequent investigation. This support guide and resource focuses on what needs to be put in place for staff.
Second Victim
This website was designed as a resource for clinicians who are involved in a patient safety incident, their colleagues and the organisations they work for. It has been developed by a team from the Yorkshire Quality and Safety Research Group and the Improvement Academy. It is supported by the National Institute for Health Research (NIHR) Yorkshire and Humber Patient Safety Translational Research Centre. The team includes researchers, academics, and clinicians from a range of backgrounds including psychology, nursing, medicine and allied health professions.
Just Culture Network – Improvement Academy
An organisational Just Culture creates the conditions necessary for safe patient care and staff wellbeing. This ‘Just Culture’ Network is for staff from Yorkshire and Humber NHS provider (including acute, community and mental health trusts) and commissioning organisations seeking to improve the culture within these organisations.
How are you feeling NHS?
This emotional wellbeing toolkit explains the contributors to decreased emotional wellbeing and shows how to encourage improvements.
National Learning Report: Support for staff following patient safety incidents (2021) — HSIB
The purpose of this national learning report is to inform the practice of supporting staff who are involved in and following patient safety incidents. Information has been drawn from the academic literature; from the knowledge and experience of HSIB’s staff, gained during their own previous careers and during HSIB investigations; and from case studies. The report brings these together to share findings that organisations may consider when developing their own programmes.
The National Guardian’s Office – Freedom to Speak Up
If you are a member of staff in the NHS in England and are concerned about a safety incident where you work, the National Guardian’s Office provides advice on the Freedom to Speak Up Guardian role and supports the Freedom to Speak Up Guardian network. The office also exercises its discretion to review cases referred to it where there is evidence that an NHS service has not responded appropriately to the safety concerns raised by its workers. All NHS trusts and foundation trusts have appointed Freedom to Speak Up (FTSU) Guardians. Details about your local FTSU Guardian can be found within your trust or a directory of FTSU Guardians is available on the National Guardian’s Office website.
Protect – Speak up stop harm
Protect (formerly Public Concern at Work) is a national charity which aims to encourage speaking up in the workplace.
For Employees – Speak Up
The Speak Up helpline is a free, independent and confidential helpline for people working in NHS and Social Care organisations in England, operated by Social Enterprise Direct Limited on behalf of the Department of Health and Social Care.
When healthcare harms – who cares?
This blog from Joanne Hughes discusses how staff need care and support in order to recover themselves and, crucially, so that they feel psychologically safe and are fully supported to be open and honest about what has happened.
A support initiative at Chase Farm Hospital
In this series of blogs, Carol Meshany talks about an example of good practice – operating a 24-hour staff support unit for those involved in patient safety incidents.
World Healthcare Organisation
WHO sets out the connection between healthcare worker safety and patient safety and the importance of considering the two concepts side-by-side.
Employee assist schemes, trade union and the relevant royal college may also be able to offer information and support to staff. NHS Trusts may also offer a Critical Incident Staff Support Pathway (CrISSP), a Trauma Risk Management (TRiM) service or Schwartz rounds locally.
Useful information and support for everyone
Patient Safety Commissioner
This site is for everyone interested in promoting patient safety and making sure that patients’ voices are heard.
Patient Safety Learning
Patient Safety Learning is a charity and independent voice for improving patient safety which aims to harness the knowledge, enthusiasm and commitment of healthcare organisations, professionals and patients for system-wide change and the reduction of harm. They support safety improvement through policy, influencing and campaigning and the development of ‘how to’ resources such as the hub to share learning for patient safety.
Broken trust: Making patient safety more than just a promise (PHSO)
In this report from the Parliamentary and Health Service Ombudsman (PHSO) ‘Broken trust: Making patient safety more than just a promise’, it has been stated that the NHS must do more to accept accountability and learn from mistakes, particularly when there is serious harm or, worse, loss of life.
HSIB’s approach to patient and family engagement during investigations
This report sets out the family engagement process at the Healthcare Safety Investigation Branch (HSIB). It also summarises the feedback received to date from the families who have been involved in investigations. The purpose is to share the family engagement process with other healthcare organisations involved in patient safety investigations in hope to raise awareness of the value of an effective family engagement process in such investigations.
Behavioural insights into patient motivation to make a claim for clinical negligence (NHS Resolution)
NHS Resolution published a paper in 2018 based on research looking at the factors which lead patients to consider a claim for compensation when something goes wrong in their healthcare. Undertaken in partnership with The Behavioural Insights Team (BIT), the research considered the experience reported by 728 patients who agreed to participate in a survey, including 20 who volunteered for a subsequent in depth telephone interview with the BIT team.
Being Fair (NHS Resolution)
NHS Resolution published a report in 2019 on supporting a just and learning culture for staff and patients following incidents in the NHS in 2019. A just and learning culture is the balance of fairness, justice, learning – and taking responsibility for actions. It is not about seeking to blame the individuals involved when care in the NHS goes wrong. It is also not about an absence of responsibility and accountability. This webinar from Suzette Woodward also gives an idea of the content of the report and it’s purpose.
AvMA – Harmed patient pathway
Action Against Medical Accidents (AvMA) and the Harmed Patients Alliance jointly launched a project in February 2021 to develop a ‘Harmed Patient Pathway’ for utilisation by the NHS when there has been harm caused to patients. It is based on the concept that health providers owe a moral duty of care specifically to people who have been affected by healthcare harm, be it the patient themselves or people close to them.
Meaningful apologies | SPSO
The Scottish Public Services Ombudsman (SPSO) has produced guidance outlining what you need to do to make a meaningful apology.
Restorative approach to healthcare harm (Victoria University of Wellington)
Researchers from Te Herenga Waka—Victoria University of Wellington’s (New Zealand) Diana Unwin Chair in Restorative Justice have contributed to a new film that explores how a restorative approach can promote healing and learning following an episode of healthcare harm. Jo Wailing also delivers a related presentation as part of the Yorkshire Quality and Safety Research seminar series.
Forgiveness: Stories from the Front Line
BBC Radio 4 cover the topic of surviving and restoring your life when something truly appalling is done to you. Trevor’s student daughter took her own life. Can he forgive the system that failed her?
Research papers
Patient and family involvement in serious incident investigations from the perspectives of key stakeholders: a review of the qualitative evidence. Journal of patient safety. Ramsey, L., McHugh, S., Simms-Ellis, R., Perfetto, K., & O’Hara, J. K. (2022).
Humanizing harm: Using a restorative approach to heal and learn from adverse events. Health Expectations. Wailling, J., Kooijman, A., Hughes, J., & O’Hara, J. K. (2022).
