Patient Safety Incident Response Plan

This Patient Safety Incident Response Plan (PSIRP) sets out how Essex Partnership NHS Foundation Trust will respond to patient safety incidents reported by staff and patients, their families and carers as part of our work to continually improve the quality and safety of the care we provide.

The NHS is changing the way it embraces patient safety, moving from a focus on individual incidents and issues to a more comprehensive look at system improvement with a holistic review of safety across the organisation.

EPUT was one of the first ‘early adopter’ NHS Trusts to introduce a Patient Safety Incident Response Plan as part of the new framework which aims to allow organisations to focus learning response resources on areas where improvement will have the greatest impact, based on their local incident profile and existing improvement work.

Other types of response exist to deal with specific issues or concerns. Examples of such responses include complaints management, claims handling, human resources investigations into employment concerns, professional standards investigations, coroners inquests or criminal investigations. The principle aims of each of these responses differ from the aims of a patient safety response and are outside the scope of this Plan

The new Patient Safety Incident Response Framework (PSIRF) and the national Patient Safety Incident Response standards means that rather than investigate all of the more adverse patient safety incidents in the way we used to under the previous framework, we now take an approach which includes:

• Enabling resources to be focused more effectively on the identified areas with the greatest potential for patient safety improvement; and enable responses to look at incidents that would not have met the serious incident criteria but where important learning can still be gained.
• Focusing learning response on where we can improve, using new learning responses including after action review, swarm huddle and multidisciplinary team reviews.
• Adopting modern approaches of patient safety science, which focus on complex work systems and processes in order to achieve safer care and service to our patients.

Patient Safety Incident Investigations (PSIIs) will be undertaken for the following patient safety incidents:

• Those that meet the Never Events criteria 2018, or its replacement 
• Those patient safety incidents that meet the learning from deaths criteria
• Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care (incidents meeting the learning from deaths criteria)
• Locally led PSII or involvement with other NHS care providers in PSII may be required in other circumstances set out in the National event response
• Requirements
• Any incident where there are opportunities for new learning and that pose significant safety risks

Involvement of those affected by incidents

NHS England has described how NHS organisations should involve patients in patient safety in its – Framework for Involving Patients in Patient Safety (2021) and Patient Safety Strategy published in 2019 and updated in 2021.

The involvement of patients in their care and in the development of safer services is a priority for the NHS and people now have a greater expectation that they will be involved in their care and in ensuring it is safe.

EPUT is committed to adopting the Framework for Involving Patients in Patient Safety. We have recruited Patient Safety Partners (PSPs) as part of our commitment to delivering safe and high quality care. The main role of our PSPs will be to work with us to ensure that we prioritise the safety requirements of our patients, thereby maximising the things that go right and minimising the things that go wrong for people receiving our services.

When investigating a PSII we will always offer those affected by the incident, involvement in our learning responses. This will include patients and/or their families, carers or supporters as well as any staff involved. The contribution of those affected is important to inform the learning response findings and improve care delivery for the future. Patient’s and/or their families, carers or supporter  will be offered a family liaison officer (FLO) to help consider types of support available and act as a single point of contact between  for the Trust or learning response team. The family liaison team can be contacted by emailing epunft.patient.safetyincidents@nhs.net

Our Patient Safety Incident Response Plan will continually evolve with national developments and will align with the EPUT Culture of Learning (ECOL) safety programmes. This represents our commitment to excellence and our willingness to learn from the actual experience of others.

The patient safety incident management team can be contacted on epunft.patient.safetyincidents@nhs.net and the EPUT Lessons Team can be contacted on epunft.lessonsteam@nhs.net