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PSIs cover a broad range of incidents...

In general the first steps are :

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CLICK ABOVE FOR MORE INFORMATION...

For the purposes of Form R, you need to record any complaints and significant events that have been formally investigated by your employing organisation / Health Education England / professional body / external organisation (e.g. MNSI), or that are currently unresolved, since your last ARCP. This will be part of your sign-off discussion prior to the ARCP, and the issues may be discussed at your ARCP. The ARCP panel is interested in what you have learnt as well, and you must reflect on any significant incidents, complaints, and investigations in your e-portfolio.

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The avoidance of unexpected or unintended harm during the provision of healthcare 

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The avoidance of unexpected or unintended harm during the provision of healthcare 

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The NHS England National Patient Safety Strategy (2019), supported by the National Patient Safety Team, sets out a framework to minimise safety incidents and drive improvement in safety and quality. Underpinning the strategy are the foundations of safe cultures and safe systems. Through insight into incidents and systems, with involvement of staff and patients, safety improvement can be made.

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The NHS Patient Safety Strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems.

Contents

The NHS Patient Safety Strategy

The NHS Patient Safety Strategy sets out how the NHS will support staff and providers to share safety insight and empower people - patients and staff - with the skills, confidence and mechanisms to improve safety. Getting this right could save almost 1,000 extra lives and £100 million in care costs each year.

The strategy is evolving over time to ensure it is supporting the NHS to meet its current challenges and priorities, remains relevant and can impact on the areas where need is greatest.

The National Patient Safety Team are supporting the NHS to achieve the strategy's aims through a series of programmes and areas of work. All of this work relates to the strategy's foundations of 'patient safety culture' and 'patient safety systems', and the three strategic aims 'insight', 'involvement' and 'improvement'.

Key documents and updates

Read this blog from Aidan Fowler, National Director of Patient Safety, to find out about the latest updates for 2023 and 2024.

Progress so far

Emerging evidence shows that the NHS Patient Safety Strategy is making progress towards the impact we anticipated in 2019: saving an additional 1,000 lives and £100 million per year. Latest figures from June 2023 indicate we are halfway to achieving that aim.

Our NHS Patient Safety Strategy: Progress so far webpage details some highlights of where the strategy is having an impact, along with a selection of case studies.

You can also find further detail on the strategy's key initiatives via the links below:

Key components of the strategy

Aidan Fowler, National Director of Patient Safety, introduces the NHS Patient Safety Strategy.

Hugh McCaughey - A key principle of the NHS Patient Safety Strategy is continuous improvement. Hugh McCaughey, National Director of Improvement, discusses the relationship between Quality Improvement and patient safety.

Dr Suzette Woodward, director of the Sign up to Safety Campaign that ran from 2014 to 2019, describes the equally important behaviours of kindness and civility that support patient safety.

There is a clear interest in widening patient safety thinking beyond things that go wrong. Dr Suzette Woodward, describes the concept of Safety II and the importance of also looking at why things routinely go right in healthcare.

The National Reporting and Learning System (NRLS) has been at the heart of NHS patient safety insight since 2004, but it uses outdated technology, Lucie Musset, product owner for a new digital system to replace the NRLS describes what it will do and how it will benefit patient safety.

Developing the strategy

Between December 2018 and February 2019 we held a consultation on our original set of ideas for a national patient safety strategy for the NHS.

We received 527 contributions from organisations and individuals (staff, patients and carers), and attended stakeholder meetings and engagement events. We also held workshops with staff, patients and senior leaders across the country and hosted online discussions. See Annex 1 above for a summary of the results of the consultation.

You can also view our original proposals and the consultation questions in our consultation discussion document .

Contact us

If you would like further information about the NHS Patient Safety Strategy, or have any questions, please email patientsafety.enquiries@nhs.net.

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The NHS Patient Safety Strategy describes how the NHS will continuously improve patient safety, building on the foundations of a safer culture and safer systems. The NHS Patient Safety Strategy sets out how the NHS will support staff and providers to share safety insight and empower people - patients and staff - with the skills, confidence and mechanisms to improve safety.

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October 2022

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The report of the independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent.

Applies to England

Documents

Details

On 13 February 2020 the Minister of State, DHSC, confirmed in Parliament that, following concerns raised about the quality and outcomes of maternity and neonatal care, NHS England and NHS Improvement (NHSEI) had commissioned Dr Bill Kirkup CBE to undertake an independent investigation into maternity and neonatal services at East Kent Hospitals University NHS Foundation Trust. The terms of reference were published on 11 March 2021.

The primary reason for this report is to set out the truth of what happened, so that maternity services in East Kent can begin to meet the standards expected nationally, for the sake of those to come. This report identifies 4 areas for action. The NHS could be much better at:

identifying poorly performing units

giving care with compassion and kindness

teamworking with a common purpose

responding to challenge with honesty

Thank you for your feedback

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Maternity and neonatal services in East Kent: 'Reading the signals' report

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The report of the independent investigation led by Dr Bill Kirkup on maternity and neonatal services in East Kent.

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March 2022

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Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust.

Applies to England

Documents

Request an accessible format.

If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email publications@dhsc.gov.uk. Please tell us what format you need. It will help us if you say what assistive technology you use.

Details

This review of maternity services at the Shrewsbury and Telford Hospital NHS Trust independently assesses the quality of investigations relating to newborn, infant and maternal harm at the trust.

This final report of the review covers the findings, conclusions and essential actions of this independent review of maternity services.

Based on a review of all family cases that formed part of this investigation, the final report outlines:

system-wide learnings

immediate and essential actions to improve maternity care

It follows a previous report on emerging themes and trends identified from examination of 250 fully assessed cases, which was published in December 2020.

The Independent Maternity Review (known as the Ockenden review) is led by senior registered midwife Donna Ockenden.

Thank you for your feedback

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Findings, conclusions and essential actions from the independent review of maternity services at the Shrewsbury and Telford Hospital NHS Trust.

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Every health and care professional must be open and honest with patients and people in their care when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that health and care professionals must:

tell the person (or, where appropriate, their advocate, carer or family) when something has gone wrong

apologise to the person (or, where appropriate, their advocate, carer or family)

offer an appropriate remedy or support to put matters right (if possible)

explain fully to the person (or, where appropriate, their advocate, carer or family) the short and long term effects of what has happened.

Health and care professionals must also be open and honest with their colleagues, employers and relevant organisations, and take part in reviews and investigations when requested. They must also be open and honest with their regulators, raising concerns where appropriate. They must support and encourage each other to be open and honest, and not stop someone from raising concerns.

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The vast majority of people who work in health and social care wish to provide the very best care they can. There is very rarely intent by staff to provide care that did not go as expected or planned.

When clinical incidents do occur, they can have a real and deep impact on peoples' lives. Regardless of the level of harm incurred, patients and families have a right to receive a meaningful apology and explanations for what happened as soon as possible.

We know this is not easy, but being open and transparent with patients when treatment or care goes wrong is always the right thing to do - this is often referred to as the 'Duty of Candour'.

Those working within healthcare may have heard of the terms statutory and professional duty of candour but may not be sure of the differences that exist between them. This uncertainty can result in the duty of candour not being fulfilled effectively.What is Professional Duty of Candour?

The professional duty of candour is a professional responsibility to be open and honest with patients and families when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This includes saying sorry and taking action to put things right where possible. It is always the right thing to do and is not an admission of liability.

Regulators of specific healthcare professions oversee the professional duty of candour.

Failure to comply with the principles of the professional duty of candour can lead to disciplinary action being taken.
Fulfilling the professional duty of candour
As soon as you realise something has gone wrong with the care of a patient, you should speak to the patient or their family.

Where possible, speak to them face to face in a quiet, neutral space. If it is not possible to speak face to face, try and ascertain what their preferred approach would be, for example, a virtual meeting or a telephone call.

Ensure there is someone available to support them, such as a friend, relative or professional colleague.

Provide a true account of what has happened including what is known. Provide the opportunity for questions to be asked.

It is okay not to immediately know all the facts but you should be clear about what has and has not yet been established.

Saying sorry is crucial. You must apologise from the outset for the harm caused, regardless of the level of harm or fault. Saying sorry is always the right thing to do and is not an admission of liability.

Depending on the circumstances, it may be more appropriate to promptly escalate the situation to a senior member of your team or organisation and request they speak to the patient (or family) on your behalf.

Ensure the details of a single point of contact are provided. This should be someone who will be involved throughout the process and can regularly update the patient or family.

Irrespective of the level of harm incurred, you should document should document and report the incident through your organisations reporting process, and include the actions taken.

Those responsible for governance within your organisation can advise you if you are unsure whether the statutory duty of candour also applies.
What is the statutory duty of candour?
The statutory Duty of Candour is laid out in Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It puts an overarching legal duty on health and social care providers to be open and transparent with people using services, and their families, in relation to their treatment or care. It is overseen by the Care Quality Commission or CQC.

As well as the overarching duty, regulation 20 also sets out some specific actions that providers must take when a notifiable safety incident occurs.

A 'Notifiable safety incident' is a specific term defined within the duty of candour regulation and should not be confused with other types of safety incidents or notifications.

A "notifiable safety incident" must meet all of the following specific criteria:

1. It must have been unintended or unexpected

2. It must have occurred during the provision of an activity the CQC regulates

3. In the reasonable opinion of a health care professional, the notifiable safety incident could, or already appears to have, resulted in death, or severe or moderate harm to the person receiving care. This includes prolonged psychological harm

The CQC expect to see organisations act promptly as soon as a notifiable safety incident has been discovered.

It is an offence for a CQC regulated organisation to fail to comply with the duty. Failure can result in enforcement activity ranging from warning or requirement notices to criminal prosecution.

Organisations must have clear policies and procedures in place and ensure staff understand their responsibilities. The CQC will also expect senior managers to demonstrate that they have a safe culture where staff feel able to speak up and are supported to carry out the duty of candour as appropriate .
Fulfilling the statutory duty of candour
When something qualifies as a "notifiable safety incident", the specific steps laid out in Regulation 20 must be carried out "as soon as reasonably practicable".

This means opening conversations with the "relevant person".

The 'relevant person' is defined in the regulation as either the person who was harmed or someone acting lawfully on their behalf

Someone may act on the behalf of the person who was harmed if the person:

· has died

· is under 16 and not competent to make decisions about their care or the consequences of the incident

· is over 16 and lacking mental capacity. This is in accordance with the Mental Capacity Act 2005.

Regulation 20 states that organisations must:

1. Tell the relevant person, face-to-face, that a notifiable safety incident has taken place.

2. Say Sorry

3. Provide a true account of what happened, explaining whatever is known at that point.

4. Explain to the relevant person what further enquiries or investigations will take place

5. Follow up by providing this information, and the apology, in writing, and providing an update on any enquiries.

6. Keep a secure written record of all meetings and communications with the relevant person.
Key messages
Being open and transparent with patients and their families when treatment or care goes wrong is key to good duty of candour compliance.

Remember: Saying sorry is always the right thing to do and is not an admission of liability.

Always be compassionate towards the needs of the patient and their family.

Ensure conversations are bespoke to their needs, consider the sensitivities of the situation and always ensure that all communication is personalised and empathetic.

Following these points will help you effectively fulfil both the professional and statutory duties of candour.

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Duty of candour animation - NHS Resolution

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Our duty of candour animation offers guidance on the importance of being open and honest. Being open and honest with patients and those close to them is always the right thing to do and is often referred to as the duty of candour. We have ...

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When PSIs occur all staff have a duty and a responsibility to report what happened, actively learn, and prevent such failings happening again. This is a fundamental principle of providing

safe and harm free care for every patient.

In order to achieve a restorative just and learning culture in the aftermath of when care has not gone as expected or planned, three questions should be asked (Dekker 2017):
1) Who is hurt?
2) What do they need?
3) Whose obligation is it to meet that need?

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Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm

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Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm

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This is a broad definition and clearly includes a wide range of incidents that occur throughout the course of providing care. Reporting and learning principles apply for all incidents regardless of the level of harm. Prevented patient safety incidents (or near misses) can provide the most valuable learning for the NHS because they can flag up problem areas where there is potential for things to go wrong in the future. They can also highlight ways in which either the staff or various controls and defences have prevented the incident harming the patient (or have minimised the harm caused).

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All reported incidents are reviewed by a member of your local risk management or patient safety team and graded based on level of harm NHS England » Policy guidance on recording patient safety events and levels of harm . The level of harm combined with the likelihood of the incident recurring provides a measure of the potential level of risk posed to patient safety. PSIs are commonly grouped in to categories to allow surveillance of trends for further analysis, learning that may feed in to existing QI work or suggest a new area for improvement focus.

In the majority of cases, you as a trainee, will not be directly involved in this process. Local risk management or patient safety teams usually feedback trends, themes and learning through local safety newsletters, safety huddles, risk management meetings, PROMPT training and other forums. This should be covered at your local trust induction.

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Introduction

This policy guide sets out expectations for the recording of patient safety events and their associated levels of harm when using the 'Learn from patient safety events' service. It provides the definitions of the patient safety event types that have been included in the new LFPSE service. This publication supersedes any previous guidance for the NRLS and is the official policy guidance for recording patient safety events to the LFPSE service.

Further contextual information on who should use this service, how to implement it, and other frequently asked questions (FAQs) is available online.

Recording the appropriate level of harm associated with a patient safety incident is important so that:

we have an accurate description of the event and its impact on the patient, based on the best information at the time

there is consistency and comparability within the organisation's own data

the national patient safety team can use the recorded information to analyse, triage and learn from consistent and high-quality data

other policies such of Duty of Candour can be enacted appropriately.

Incident recording is mandatory in certain circumstances (see the LFPSE FAQs for further details) and very much encouraged in all others. If in doubt, it is always better to record a patient safety incident using the available information and best judgement, and LFPSE is designed to support record updates as and when new information becomes available. There are certain mandatory reporting requirements set out in CQC regulations, but ultimately determining when an incident has occurred, the extent to which that incident has caused harm, and the level of harm caused, are all judgements.

To support these judgements, this policy guide sets out the definitions of Incident and Good Care event types, level of harm, and answers some frequently asked questions relating to the recording of incidents.

Definitions - event types

The full definitions of the patient safety event types in this guide are:

Patient Safety Incident - Something unexpected or unintended has happened, or failed to happen, that could have or did lead to patient harm.

What does this mean? - This event type encompasses all patient safety incidents, including "near misses". Select this option if you know that something did not go as intended or expected - whether an act or an omission - and as a direct result the incident could have or did harm one or more patients.

Good Care - An example of good care that can be learned from

What does this mean? - Positive learning opportunities. Select this option if you want to share experiences or learning from things that have gone well whilst delivering care.

Definitions - harm grading

In the NHS, degree of harm recording relates to the actual impact on a patient from the particular incident being reported. Just as in NRLS, LFPSE maintains this principle. Patient safety incident harm definitions should always be applied based on the best information about the actual impact of the incident at the time of recording. The harm grading can be reviewed and updated as more information becomes available, but should not be used to speculate about, for example more severe "potential harm" if that does not appear to have been caused.

The descriptions of the different levels of physical harm in this document are not intended to alter the thresholds of different levels of harm that were described in previous NRLS guidance. They have been developed to provide more clarity and to support more consistent harm grading, but are based on the thresholds that have been used in the NRLS for some time.

A new addition in this policy guide and in relation to patient safety incident data in the LFPSE service relates to specific capture of information on psychological harm. Previously in the NHS, harm grading included psychological harm as well as physical harm within one measure. Following feedback from staff, patients and families, physical and psychological harm have been separated out and each can now be recorded in the LFPSE service.
Where practical, it is good practice to discuss the level of harm with the patient affected and to consider the patient's perspective on the harm definitions stated below.
The full definitions of the harm gradings are as follows:

Physical harm
No physical harm
No physical harm
Low physical harm
Low physical harm is when all of the following apply:

minimal harm occurred - patient(s) required extra observation or minor treatment

did not or is unlikely to need further healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit

did not or is unlikely to need further treatment beyond dressing changes or short courses of oral medication

did not or is unlikely to affect that patient's independence

did not or is unlikely to affect the success of treatment for existing health conditions.

Moderate physical harm
Moderate harm is when at least one of the following apply:

has needed or is likely to need healthcare beyond a single GP, community healthcare professional, emergency department or clinic visit, and beyond dressing changes or short courses of medication, but less than 2 weeks additional inpatient care and/or less than 6 months of further treatment, and did not need immediate life-saving intervention

has limited or is likely to limit the patient's independence, but for less than 6 months

has affected or is likely to affect the success of treatment, but without meeting the criteria for reduced life expectancy or accelerated disability described under severe harm.

Severe physical harm
Severe harm is when at least one of the following apply:

permanent harm/permanent alteration of the physiology

needed immediate life-saving clinical intervention

is likely to have reduced the patient's life expectancy

needed or is likely to need additional inpatient care of more than 2 weeks and/or more than 6 months of further treatment

has, or is likely to have, exacerbated or hastened permanent or long term (greater than 6 months) disability, of their existing health conditions

has limited or is likely to limit the patient's independence for 6 months or more.

Fatal (previously documented as 'Death' in NRLS)
You should select this option if, at the time of reporting, the patient has died and the incident that you are recording may have contributed to the death, including stillbirth or pregnancy loss. You will have the option later to estimate to what extent it is considered a patient safety incident contributed to the death.

Psychological harm

Please note that when recording psychological harm, you are not required to make a formal diagnosis; your answer should be an assessment based on the information you have at the point of recording and can be changed if further information becomes available.
No psychological harm
Being involved in any patient safety incident is not pleasant, but please select 'no harm' if you are not aware of any specific psychological harm that meets the description of 'low psychological harm' or worse. Pain should be recorded under physical harm rather than psychological harm.
Low psychological harm
Low psychological harm is when at least one of the following apply:

distress that did not or is unlikely to need extra treatment beyond a single GP, community healthcare professional, emergency department or clinic visit

distress that did not or is unlikely to affect the patient's normal activities for more than a few days

distress that did not or is unlikely to result in a new mental health diagnosis or a significant deterioration in an existing mental health condition

Moderate psychological harm
Moderate psychological harm is when at least one of the following apply:

distress that did or is likely to need a course of treatment that extends for less than six months

distress that did or is likely to affect the patient's normal activities for more than a few days but is unlikely to affect the patient's ability to live independently for more than six months

distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, but where recovery is expected within six months

Severe psychological harm
Severe psychological harm is when at least one of the following apply:

distress that did or is likely to need a course of treatment that continues for more than six months

distress that did or is likely to affect the patient's normal activities or ability to live independently for more than six months

distress that did or is likely to result in a new mental health diagnosis, or a significant deterioration in an existing mental health condition, and recovery is not expected within six months

When are harm grading fields mandatory?

If an incident has happened where a person(s) is directly involved (regardless of impact/harm) then recording levels of physical and psychological harm is mandatory in the LFPSE system.

Below are detailed examples of patient safety incident events and where the recording of harm is required or not:

Incident where a patient was harmed: for example, patient given a medication to which they have a known allergy

Harm grading required: yes

Details for LFPSE recording: Select the appropriate level of actual physical and/or psychological harm, within the categorical fields and provide further details in the "Describe what happened" free text section, including how the issue was identified.

Incident where the patient sustained no harm: for example, patient given incorrect medication, but to no ill-effect, physically or psychologically

Harm grading required: yes

Details for LFPSE recording: These should be recorded with no physical/no psychological harm within the categorical fields and provide further details in the "Describe what happened" free text section, including how the issue was identified.

Incident where a patient was involved, but harm to the patient was prevented: for example, medication stored at the incorrect temperature was selected, but not administered to the patient because temperature control issues were identified in time; or, patient invited for the wrong procedure, but the invited patient queried the procedure prior to attending

Harm grading required: yes

Details for LFPSE recording: LFPSE also records "near miss" or 'prevented incidents' in which specific patients are identifiable, but the incident resulted in no harm due to a timely intervention. These should be recorded with no physical/no psychological harm, within the categorical fields, and further details provided in the "Describe what happened" free text section, including how the issue was identified, and how the intervention protected the patient(s).

Incident where no patients were involved: for example, medicine storage issues identified before medicines are selected to be administered to any patients; or, oxygen supply disruption in patient areas but patients were not present at the time; or, temporary power issues in a computer which holds a ward's falls assessment templates, though no patients were admitted during the time the system was off-line

Harm grading required: no

Details for LFPSE recording: This should be recorded with 0 patients within LFPSE as no specific patient can be identified as having been involved, and so no patient information need be recorded. You will however be asked if the incident creates an imminent risk (within 2 weeks) of severe harm or death, and if so, if there are any specific patient populations who might be at most risk. This information is used to triage such risks for review at the national level. Answers are understood to be subjective and speculative.

Incident where multiple patients were involved: for example, an overrunning outpatient clinic requiring multiple patients to be rebooked for their follow up appointments; or, infection control - outbreak in ward area; or, faulty CT scanner preventing multiple patients from having their scans

Harm grading required: yes

Details for LFPSE recording: LFPSE allows you to record the details for up to 10 individual patients affected by one incident; the harm fields must be completed for each of these. This field can be updated as more information becomes available. If a patient safety incident affects more than 10 patients, you need only record one patient's details with the most serious single harm, physical or psychological, in the categorical fields and can outline the other impacts within the "describe what happened" free text field including the number of patients involved.

Recording guidance questions and answers

The questions and answers presented below represent questions or issues that frequently arise in relation to patient safety event recording. If you have a question that is not covered below please send it to england.patientsafetyhelpdesk@nhs.net.

1. Do we only record patient safety incidents that we know have occurred in our organisation?

No. You should record patient safety incidents whether they occurred during an episode of care at your organisation or occurred during care provided by another healthcare provider if you are the first provider to become aware of them.

For example, if a pressure ulcer was present on hand over to your organisation from a previous provider, it should still be recorded as a patient safety incident, stating 'No' to the question "Did the incident occur whilst the patient was under your organisation's care?" and documenting the organisation where the care was provided previously.

NB: this record will then become visible to, and "owned by" that provider. Depending on the provider type and location, your organisation may or may not maintain visibility of that record.

If a patient presents to your organisation with a pressure ulcer and has not been under the care of a health care provider (see FAQs for details on which services this includes) prior to presentation, then this does not align with the definition of a patient safety incident and does not need to be recorded to LFPSE. However, if the pressure ulcer were then to deteriorate further during the healthcare episode, an incident should be recorded.

This documentation supersedes previous NRLS documentation ( Implementing the pressure ulcer framework in local reporting systems and reporting to NRLS 2019) specifically in relation to:

Recommendation 11 - 'The definition of a new pressure ulcer within a setting is that it is first observed within the current episode of care.'

Recommendation 15 - 'Reporting of all pressure ulcers grade 2 and above on admission (POA) (which is observed in the skin assessment on admission to that service) should be incorporated into local monitoring systems.

2. Can category of pressure ulcer be matched to a LFPSE degree of harm?

No, the degree of harm depends on the actual impact for this patient as a result of the patient safety incident and does not corelate with the category of pressure ulcer. For example, a patient with a category 3 pressure ulcer could fall into moderate harm because they needed additional healthcare for 3 months.

However, if the same ulcer was on the heel and expected to affect mobility even after healing, then that would be graded as severe harm. Each pressure ulcer must be assessed for degree of harm, using category of pressure ulcer only as a guide and the reason for the level of harm selected should be demonstrated in the free text description of the incident.

If a patient has multiple pressure ulcers that developed by the same mechanism, then only one incident need be recorded. The harm associated with this incident would be the actual level of harm to the patient (i.e., the highest level of harm the patient has incurred from any or all of the pressure ulcers).

If a patient has multiple pressure ulcers which developed due to different mechanisms (i.e, one develops due to a monitoring device, and the other is related to profiling bed equipment), two distinct incidents have occurred and should be recorded as such.

3. How are suicides, self-harm and deaths from drugs and alcohol recorded as patient safety incidents?

The following summarises the guidance for organisations providing specialist mental health services. Further detailed guidance for mental health service providers (including self-harm and restrictive practice) will be published shortly:

NOTE: 'Former patient' is defined as any patient who has been discharged from the Trust's services or who does not have a current open episode for inpatient or community care.

As a general guide, if a patient dies from actual or apparent suicide within 6 months of discharge, or during a further referral to Mental Health (MH) services, a judgement needs to be made as to whether a patient safety incident may have occurred. That incident could be something such as inappropriate discharge or failure in communication. If it is determined that an incident has occurred, the incident should be recorded locally and to the LFPSE service.

It is less likely that death of a former patient more than 6 months after discharge will indicate a patient safety incident has occurred. However, judgment can still be applied to determine if a patient safety incident should be recorded.

The free text incident description should demonstrate how the incident meets the reporting criteria i.e. whether patient is former or current, details of the act or omission that indicates it is or might be a patient safety incident, clearly indicating the actual injuries, or stating that death occurred.

Whilst MH services rightly are mindful that determining if a death is suicide is the role of the coroner, all contextual information that would suggest the likelihood of fatal self-harm needs to be included in the initial incident record.

It is accepted that sometimes toxicology or wider information-gathering is needed to determine if a death is from self-harm, accidental or natural causes. MH services may have to initially record the event on the basis that they suspect rather than can confirm self-harm, but they should not routinely report all unexpected deaths solely because the possibility of self-harm cannot yet be excluded. The CQC accepts recording at a later date in circumstances where self-harm did not initially appear a likely cause of death.

4. Can I change the level of harm of an incident recorded to the LFPSE service after initial record submission?

Yes. As new information becomes available, the incident harm grades (and any other relevant information) can be amended to reflect the update. Please complete the free text description to explain any changes made to the harm grades.

5. How do we select the degree of harm when the ultimate clinical impact of a patient safety incident is not known?

A best assessment at the time of the incident should be carried out and if, at a later date, more information is received, the incident degree of harm and other details about the incident can be amended.

6. Can I still record an incident's level of psychological harm if I am not a trained mental health professional?

Yes, all staff users should be able to make an initial selection of levels of harm on both the physical and psychological scales as it is understood to be a snapshot of limited information at this stage. A formal diagnosis is not required - only the recorder's clinical judgement. To support this, we have:

Worked with users to provide clarified definitions and examples for each, to help guide decision-making.

Mirrored the language used in the physical and psychological scales, to make it simpler for recorders.

Provided the ability to amend all fields including these, should further information become available at any point. This can be done by the original recorder, or by designated users with enhanced permissions at the review stage.

It is important that all records for incidents are submitted with this data, even if it is an initial best-guess, to enable local and national prioritisation and response.

7. What if a death is considered to be due to the natural disease process but a patient safety incident occurred during the provision of care that did not lead to the death?

Based on what is known at the time of recording, a judgement would be needed by the reporter as to the actual impact on the patient from the incident they are reporting. Where it is considered that the incident could have resulted in the death of the patient, rather than the progression of their natural disease, this should be recorded as an incident with a degree of harm selected as fatal. Where the impact is not considered to have resulted in the fatality, a lower level of harm can be recorded.

The supplementary question "how much did the incident contribute to the outcome for the patient?" allows the reporter to indicate their best assessment of the extent of association between incident and outcome.

8. Can we re-classify incidents recorded as fatal if it is later found the death was due to natural causes and not the incident that occurred?

Yes. If it is considered, after review of the circumstances, it is unlikely the incident was associated with the death, the harm level can be downgraded to reflect more accurately the actual harm the incident likely led to, and a rationale in the free text field for why this has been done should be included.

9. Additional observations are taken after an inpatient fall, so does this make all falls low harm?

Levels of harm should be selected based on the information available about the presentation of the patient at the time: observations may help to establish this, but taking them to ascertain the presence or absence of neurological harm does not in and of itself equate to harm level. Should any initial observations be abnormal and necessitate an extended observation period, and/or treatment, this may indicate a higher degree of harm has been caused.

Each incident should be judged individually, based on the LFPSE definitions and examples, and please note that all of the statements in the definition of low harm must apply for the level of physical harm selected to be "low".

10. Are falls resulting in fractured hips classed as severe harm?

A patient who has fractured a hip from an inpatient fall is unlikely to regain the levels of mobility and independence they had prior to the fall, in which case the degree of harm is severe. However, in a few cases the patient could recover after an extended hospital stay (moderate) or die (fatal). Each incident should be judged individually, based on the LFPSE definitions and examples.

11. What if no problems in care preceded the incident? How is harm graded? For example, a patient falls in hospital and fractures their neck of femur, but the ensuing information-gathering or review highlights no lapses in care or treatment.

If a patient falls and suffers a fractured hip, that would more often than not result in severe harm. Review of the circumstances might be unable to identify problems in care, but something unexpected or unintended still happened that resulted in harm to the patient and so the definition of a patient safety incident is met. As noted earlier, it may not always be clear if an incident has occurred or the extent to which an incident was associated with harm, but it is always preferable to err on the side of caution and report, not least as the circumstances of the fall could still represent important intelligence locally or nationally.

12. Are falls resulting in sub-dural haematoma classed as severe harm?

A patient who has a sub-dural haematoma from an inpatient fall is unlikely to regain the levels of mobility and independence they had prior to the fall; but in a few cases the patient could recover after an extended hospital stay (moderate) or die (fatal). Each incident should be judged individually, based on the LFPSE definitions and examples.

13. Does discharge from hospital indicate full recovery after a patient safety incident during hospital admission?

No, discharge from hospital does not in itself indicate full recovery. A patient may be discharged after a patient safety incident with any level of non-fatal harm: after a full recovery, or with a permanent disability. Levels of harm should be judged individually, based on the LFPSE definitions and examples, and updated accordingly if further information emerges.

14. Do the NHSE Clinical Reviewers amend the harm grading if they appear incorrect?

No, The National Patient Safety Team Clinical Reviewers do not alter any data submitted. They may identify data quality concerns and flag these to the Patient Safety Reporting Leads (RLs), who may contact the reporting organisation to offer support, advice and guidance.

15. If recording incidents that have occurred in another organisation, what should the degree of harm be?

You should record the harm level of an incident in another organisation as you would for an incident that occurred in your organisation. The harm should not be downgraded because it occurred elsewhere. The nature of typical patient pathways that cross primary, secondary and tertiary care means that effective recording and learning frequently relies on one organisation identifying and recording incidents that occurred earlier in the care pathway.

16. Does Duty of Candour apply to both the LFPSE physical and psychological scales?

Yes, any incident which is graded as having resulted in moderate or higher harm on either or both scale triggers the Duty of Candour. A severe psychological harm with low physical harm, for example, would qualify.

17. What can be recorded as a Good Care event?

A Good Care event is a positive learning opportunity from care events that have gone well whilst delivering care to and for patients.

A trust provided a recent example: " pioneering the adoption of elastomeric devices to facilitate early discharge of patients on antibiotics. Since their introduction at the beginning of the year, these devices have saved 1750 bed days for a total of 120 patients, with no increase to the number of readmissions in comparison to the baseline. Further evaluation on satisfaction and outcomes is being carried out and the evidence will be shared with the ICB ".

18. How does recording patient safety events to LFPSE relate to the new Patient Safety Incident Response Framework (PSIRF)?

Events recorded to LFPSE can form one source of data for deciding on your local priorities to be included in your Patient safety incident response plan (PSIRP). These should be considered alongside other potential issues, such as complaints, claims, Section 28 letters, and other data sources. The PSIRF module will allow users to annotate existing records with details of whether a safety response was taken forward for that issue, and any relevant findings or safety actions agreed as a result.

It may not always be the case that issues being explored under PSIRF (or according to a provider's PSIRP more specifically) are recorded as individual incidents on LFPSE. This is because providers may choose to explore broader issues including those spanning care pathways for example. These therefore do not need to be entered into LFPSE if they do not meet the definition of a patient safety incident.

Developed by the NHS England National Patient Safety Team. For any enquiries, please contact england.patientsafetyhelpdesk@nhs.net

Publication reference: PRN00444

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NHS England » Policy guidance on recording patient safety events and levels of harm

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This guidance is for users of the new Learn from Patient Safety Events (LFPSE) service, to provide context and guidance on selection of appropriate categories when recording incidents. It focuses on which Event Type is appropriate for different circumstances, and how to select the most appropriate o…

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Trusts are required to monitor and report incidents and incident review outcomes to their local networks and Integrated Care Boards (ICBs).

Your trust may also need to report a PSI to one or more national bodies

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We investigate incidents that meet the criteria as previously defined within the Each Baby Counts programme or our defined criteria for maternal deaths.

The Each Baby Counts programme was the Royal College of Obstetricians & Gynaecologists' national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour. This programme is now closed and HSIB has retained their criteria for investigation.

During our investigations we look into all clinical and medical aspects of the incident, as well as aspects of the workplace environment and culture surrounding the incident.

Babies

Eligible babies include all term babies (at least 37 completed weeks of gestation) born following labour, who have one of the below outcomes.

We don't investigate outcome for the baby was as a result of health problems that are present at birth, rather than those caused by labour, birth or the baby's care after the birth.

Intrapartum stillbirth

Where the baby was thought to be alive at the start of labour but was born with no signs of life.

Early neonatal death

When the baby died within the first week of life (0-6 days) of any cause.

Potential severe brain injury

Potential severe brain injury diagnosed in the first 7 days of life, when the baby:

Was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE) - brain injury caused by the baby's brain not getting enough oxygen.

Was therapeutically cooled (active cooling only) - when the baby's body temperature was lowered using a cooling mattress or cap, with the aim of reducing the impact of HIE.

Had decreased central tone (was floppy) and was comatose and had seizures of any kind.

Definition of labour

The definition of labour used by HSIB includes:

Any labour diagnosed by a health professional, including the latent phase of labour at less than 4 cm cervical dilatation.

When the woman called the unit to report any concerns of being in labour, for example (but not limited to) abdominal pains, contractions or suspected ruptured membranes (waters breaking).

Induction of labour (when labour is started artificially).

When the baby was thought to be alive following suspected or confirmed pre-labour rupture of membranes.

This means that for us to conduct an investigation of a maternity incident under the HSIB criteria, the mother must have been in term labour as defined by these conditions.

In line with our Directions we do not investigate neonatal cases where the mother has not gone into labour - for example when a caesarean section was performed before the mother had started having contractions or ruptured her membranes.

Maternal deaths

We investigate direct or indirect maternal deaths of women while pregnant or within 42 days of the end of pregnancy.

These incidents must meet the criteria set out in 'Saving lives, improving mothers' care', a report by MBRRACE-UK, which runs the national Maternal, Newborn and Infant clinical Outcome Review Programme.

We may investigate some maternal deaths which do not entirely fit within these two categories.

Our Directions exclude the investigation of cases where suicide is the cause of death.

Direct deaths

Direct deaths include those resulting from obstetric complications of the pregnant state (pregnancy, labour and after the birth), from interventions, omissions, incorrect treatment or from a chain of events resulting from any of the above.

Indirect deaths

Indirect deaths include those from previous existing disease or disease that developed during pregnancy and which was not the result of direct obstetric causes, but which was aggravated by the physiological effects of pregnancy in the perinatal period (during or within 42 days of the end of pregnancy).

What we can't investigate

Some maternity incidents that meet the HSIB criteria will have occurred just before our programme began nationally, or within a period where the programme had started nationally but, due to the phased rollout process, had not yet been implemented in the trust where the incident took place.

There will also be some incidents with characteristics which fall close to, but not completely within, the scope of the HSIB criteria.

Due to very specific conditions set out in the Directions that govern our programme, we have no remit to investigate these incidents and the responsibility to complete the investigation remains with the local trust.

We recognise that this may be disappointing for mothers and families who hope to see lessons from their personal experience contribute to changes at a national level to improve maternity safety.

As part of our programme we continuously assess the effectiveness of the HSIB criteria, which governs our scope of incidents for investigation. There are no current plans to change the criteria, but we hope that future adaptations will introduce some flexibility to how we can apply the criteria.

Family consent

Ideally, we prefer our investigations to start within 4 weeks of an incident taking place. We know that this is an incredibly difficult time for families, however, starting our investigation any later than this can reduce the quality of the evidence.

Families can choose how involved they want to be in our investigation. They can consent to allowing access to their medical records but then choose not to be involved at all if it's too difficult. Or we can start, the investigation once the family has given consent to access medical records, and the family can then choose to get involved further along in the investigation process.

In cases where the family does not give their consent for HSIB to access medical records, then it's unlikely HSIB could investigate/produce a report. Responsibility for conducting the investigation then returns to the trust.

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We investigate incidents that meet the criteria as previously defined within the Each Baby Counts programme or our defined criteria for maternal deaths. The Each Baby Counts programme was the Royal College of Obstetricians & Gynaecologists' national quality improvement programme to reduce the number of babies who die or are left severely disabled as a result of incidents occurring during term labour.

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About the Early Notification (EN) scheme

The Early Notification (EN) scheme is a key initiative towards achieving the delivery of safer maternity care, providing a more rapid, caring response to families in cases of severe harm, supporting a learning culture.

The scheme proactively investigates specific brain injuries at birth for the purposes of determining if negligence has caused the harm. We do this by requiring our Clinical Negligence Scheme for Trusts (CNST) members to notify us of maternity incidents which meet a certain clinical definition.

In the videos below, Sangita Bodalia, solicitor and head of Early Notification for the legal team at NHS Resolution, and Annette Anderson, midwife and head of the Early Notification clinical team at NHS Resolution, explain NHS Resolution's role and function and the Early Notification scheme.

Early Notification criteria
i) 1 April 2017 to 31 March 2020
In line with the criteria used by the Each Baby Counts programme of the Royal College of Obstetricians and Gynaecologists, the EN criteria included all babies born at term (≥37 completed weeks of gestation), following labour, that had a potentially severe brain injury diagnosed in the first seven days of life and:

Was diagnosed with grade III hypoxic ischaemic encephalopathy (HIE) or

Was therapeutically cooled (active cooling only) or

Had decreased central tone AND was comatose AND had seizures of any kind.

ii) 1 April 2020 to 31 March 2022
During the pandemic period, there were two key improvements to the investigation process:

NHS Resolution decided that no steps will be taken to investigate eligibility for compensation until the Healthcare Investigation Branch (HSIB) had completed a safety investigation.

The intention was to reduce duplication and enable trusts to focus on liaison with HSIB and the family. Instead, on receipt of the HSIB report on relevant cases, NHS Resolution overlaid an investigation into legal liability. Where families had declined an HSIB investigation, no EN investigation took place, unless the family had requested this.

The criteria for an investigation by NHS Resolution was narrowed to those cases where there is evidence of or the potential for a hypoxic brain injury. This ensured that the scheme remained focused on those cases where there is potential for a high value compensation payment.

We apply the following definition to cases: "Babies who have an abnormal MRI scan where there is evidence of changes in relation to intrapartum hypoxic ischaemic encephalopathy (HIE)".
iii) From 1 April 2022
We will continue to apply the following clinical definition to cases: "Babies who have an abnormal MRI scan where there is evidence of changes in relation to intrapartum hypoxic ischaemic encephalopathy (HIE)".

Babies whose MRI findings fall outside of the clinical definition of a brain injury could still be accepted by the EN scheme. For these babies, a multidisciplinary clinical review will take place to understand the extent of the MRI changes. If necessary, further information may be sought from the trust to help us decide whether an investigation into compensation entitlement should proceed.

Reporting requirements
i) 1 April 2017 to 31 March 2020
During this period, our Clinical Negligence Scheme for Trusts (CNST) members were required to report all maternity incidents of potentially severe brain injury to NHS Resolution within 30 days.
ii) 1 April 2020 to 31 March 2022
During this period, trust reporting to NHS Resolution was paused in order to support trusts during the pandemic. Trusts continued to report all eligible EN cases meeting the above criteria to HSIB for learning investigations to take place. HSIB then reported potential eligible EN cases to NHS Resolution for further consideration from a legal perspective.
iii) From 1 April 2022 onwards
During the pandemic period NHS Resolution and the Healthcare Safety Investigation Branch (HSIB) were able to reduce reporting requirements with qualifying Early Notification (EN) cases being reported to NHS Resolution via HSIB. This was enabled by the Control of Patient Information (COPI) notice which allowed data-sharing between NHS and public bodies. This is due to expire at the end of March 2022.

With effect from 1 April 2022, trust legal teams are to notify NHS Resolution, via the Claims Reporting Wizard, of qualifying EN cases once they have been confirmed by HSIB as under investigation. Trusts will be required to continue to report their maternity incidents to HSIB via their electronic portal.

Key actions for trusts:

Trusts' legal teams to report incidents to NHS Resolution only where HSIB have confirmed they are investigating. These will concern cases where a baby has clinical or MRI evidence of neurological injury

When reporting incidents to NHS Resolution, please include the HSIB reference in the 'any other comments' box

Please select Sangita Bodalia, Head of Early Notification at NHS Resolution on the Claims Reporting Wizard

Undertake statutory duty of candour conversations and inform families of the EN process.

Please upload the final HSIB report to the corresponding CMS file when you have received this via DTS.

Communication with families

The statutory duty of candour requires Trusts to inform families of all investigations into their care and it is vital that families involved in HSIB and EN investigations are fully informed by NHS Trusts of all processes underway and of the outcome reached.

Please note that Trusts are encouraged to continue with their initial 72 hour reviews to ensure that any learning is identified and actioned in a timely manner. 72 hour reports and investigations can be shared with NHS Resolution should a liability investigation take place.

To support the EN process we have created a dedicated web pages to provide support for patients, families or carers.

What happens once a case proceeds to an EN investigation?

Once we receive the HSIB investigation report, NHS Resolution will undertake a clinical triage to confirm whether the clinical criteria for an investigation under the Early Notification Scheme are met.

We will instruct our specialist medical lawyers to start early investigation into the potential for a compensation payment on of behalf of the NHS trust. They will work alongside trust legal and clinical teams to review relevant evidence. If needed, they will instruct expert witnesses to give their views on the standard of care provided by the organisation and apply the appropriate legal tests to determine potential eligibility for compensation. This may require a conference with counsel to take place to consider the issues.

Once the investigations have concluded, we will work with trusts to inform the family of the outcome and any next steps. This will likely include an apology (if one hasn't already been made), signposting the family to legal support and advice and, where appropriate, making any legal admissions and offers of compensation.

Please note that investigation notes and documents will be confidential and covered by legal privilege.

All information will be handled sensitively and securely, and any learning from the EN process will be shared on an anonymised basis. To learn more about how NHS Resolution will use this information, please see our privacy policy.

Contact

If you would like to get in touch with the EN team, please contact NHS Resolution directly on nhsr.enteam@nhs.net call us on 0207 811 6263.

Useful resources
Maternity incentive scheme Early Notification Progress report Maternity eLearning module: closing the loop, learning from harm Case story: Managing fetal heart rate monitoring Case story: Good practice in sepsis Case story: Learning lessons from the Darnley Supreme Court ruling Case story: Understanding the risk of maternal and neonatal hyponatraemia Case story: Good practice management of the antenatal CTG Case story: Intermittent auscultation (IA) of the fetal heart rate in the second stage of labour Case story: Managing fetal heart rate monitoring EN Report Form ENS Reporting Guide - July 2023 (for Member Trusts)

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Support for NHS trusts or member organisations - NHS Resolution

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About the Early Notification (EN) scheme The Early Notification (EN) scheme is a key initiative towards achieving the delivery of safer maternity care, providing a more rapid, caring response to families in cases of severe harm, supporting a learning culture. The scheme proactively investigates specific ...

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Late fetal loss 22⁺⁰ and 23⁺⁶ weeks and stillbirth from 24+0 showing no signs of life

All neonatal deaths where the baby is born alive from 22⁺⁰ weeks

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PMRT Programme Details | PMRT | NPEU > Perinatal Mortality Review Tool

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The National Perinatal Epidemiology Unit (NPEU) is a multidisciplinary research unit based at the University of Oxford. Our work involves running randomised controlled trials, national surveillance programmes and surveys, confidential enquiries, aetiological studies and a disease register. The resul…

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Maternal deaths

Perinatal and infant deaths

Late fetal loss

Stillbirth

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The new MBRRACE-UK system applies to England, Wales and Scotland; modified arrangements are in place for Northern Ireland.

Every Unit should have nominated staff responsible for notifying deaths via the new MBRRACE-UK system. Nominated staff members need to be authorised by senior staff in their Unit by completing the MBRRACE-UK registration form.

Maternal deaths can be notified by ringing the Oxford MBRRACE-UK office on 01865 289715 - this arrangement does not apply to any perinatal or infant deaths.

Maternal deaths eligible for notification are:
All deaths of pregnant women and women up to one year following the end of the pregnancy (regardless of the place and circumstances of the death).

Perinatal deaths and infant deaths should be reported via the online data collection system available here: www.mbrrace.ox.ac.uk

Deaths eligible for notification from 1st January 2013 onwards are:

Late fetal losses - the baby is delivered between 22⁺⁰ and 23⁺⁶ weeks of pregnancy (or from 400g where an accurate estimate of gestation is not available) showing no signs of life, irrespective of when the death occurred.

Stillbirths - the baby is delivered from 24⁺⁰ weeks gestation (or from 400g where an accurate estimate of gestation is not available) showing no signs of life.

Early neonatal deaths - death of a live born baby (born at 20 weeks gestation of pregnancy or later or 400g where an accurate estimate of gestation is not available) occurring before 7 completed days after birth.

Late neonatal deaths - death of a live born baby (born at 20 weeks gestation of pregnancy or later or 400g where an accurate estimate of gestation is not available) occurring between 7 and 28 completed days after birth.

Post-neonatal deaths - We are no longer collecting information for post-neonatal deaths because of the difficulty in ensuring complete data collection from the wide variety of places of death for these cases.

Note: Terminations of pregnancy: We only collect limited information about terminations of pregnancy that are late fetal losses, stillbirths or neonatal death. Therefore ALL terminations from 22⁺⁰ weeks are cases which should be notified plus any terminations of pregnancy from 20⁺⁰ weeks which resulted in a live birth ending in neonatal death.

Note: Births showing no signs of life (stillbirths and late fetal losses): All births delivered from 22⁺⁰ showing no signs of life are eligible for notification irrespective of when the death occurred. Please ensure that both date of delivery and date of confirmation of death are reported for these cases. Recently there has been considerable discussion about these births by the RCOG and other professional bodies. In an effort to ensure complete data collection in line with the World Health Organisation guidelines and to allow international comparisons, the eligibility criteria for MBRRACE-UK Perinatal Death Surveillance System is based on gestation at delivery irrespective of when the death occurred.

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Information about the MBRRACE-UK surveillance data collection system | MBRRACE-UK | NPEU

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The National Perinatal Epidemiology Unit (NPEU) is a multidisciplinary research unit based at the University of Oxford. Our work involves running randomised controlled trials, national surveillance programmes and surveys, confidential enquiries, aetiological studies and a disease register. The resul…

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A collaborative environment where everyone can flourish by :

Continuous learning and improvement of safety risks

Supportive, psychologically safe teamwork

Enabling and empowering speaking up by all

HOW DO YOU MAKE THESE PRINCIPLES PART OF YOUR DAY...?
(Link this to trainee case studies from individual units...?)

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Safety culture is one of the two key foundations of the NHS patient safety strategy. We define a positive safety culture as one where the environment is collaboratively crafted, created, and nurtured so that everybody (individual staff, teams, patients, service users, families, and carers) can flourish to ensure brilliant, safe care by:

Continuous learning and improvement of safety risks

Supportive, psychologically safe teamwork

Enabling and empowering speaking up by all.

Safety culture learning from best practice

We understand that organisations are at different stages of their safety culture development and that one size does not fit all. We have been working with organisations across all sectors of healthcare using a Safety-II inspired approach to learn from every day work to understand how they are supporting safety culture improvement. This has allowed us to create the Safety culture: Learning from best practice report, which also includes a number of case studies.

Within safety culture, context is everything and improving safety culture is not just about what interventions happen, it is also about how these interventions happen ie how change is implemented.

Engaging, involving and supporting patients, families, carers and staff

With the introduction of the Patient safety incident response framework there is continued emphasis on engaging and involving patients, families and staff following a patient safety incident. This supports the Just culture guide which encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way.

We know that positive patient safety and healthy organisational culture are two sides of the same coin. A culture in which staff are valued, well supported and engaged in their work leads to safe, high-quality care. The people promise describes what good staff experience should look like, including 'we are safe and healthy' and this is supported by the Culture and Leadership programme.

We are exploring how a focus on staff safety can support patient safety. This means both psychological safety and physical safety, including considering staff wellbeing, engagement, fatigue, burn-out, presenteeism, and the impact these can have on risks to patients and staff alike.

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Safety culture is one of the two key foundations of the NHS patient safety strategy. We define a positive safety culture as one where the environment is collaboratively crafted, created, and nurtured so that everybody (individual staff, teams, patients, service users, families, and carers) can flourish to ensure brilliant, safe care by: Continuous learning and improvement of safety risks Supportive, psychologically safe teamwork Enabling and empowering speaking up by all.

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Every trust has its own structure for identifying, reporting and reviewing incidents. This should be covered at your local trust induction. There are many systems for locally reporting PSIs that may be electronic or paper based. ‘Datix’ is a commonly used system in London.

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Patient safety systems are a fundamental foundation of the NHS patient safety strategy. Each of the many organisations that make up the English healthcare system (both NHS and non-NHS) has its own remit and responsibility for improving patient safety.

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2015