At Barnardo's, our purpose is clear: changing childhoods and changing lives, so that children, young people, and families are safe, happy, healthy, and hopeful.
By establishing the Patient Safety Incident Response Framework (PSIRF), we've strengthened our commitment to learning from incidents, improving safety, and supporting an open and transparent culture where children, young people, their families and staff are heard and respected.
What is the Patient Safety Incident Response Framework (PSIRF)?
The Patient Safety Incident Response Framework (PSIRF) is an NHS England approach to improving how organisations respond to safety incidents. PSIRF has replaced previous systems of investigation with a more compassionate, proportionate, and learning-focused method. PSIRF is one of the NHS Contraction elements and is a requirement of all services who have contracts for healthcare services with NHS commissioners.
PSIRF supports organisations to move away from blame and to focus, instead, on learning, natural reflection, and safety improvement; this creates a safer and more trusting culture for children, young people, their families, and staff. Safety events are explored from a ‘systems and processes’ perspective to understand how people, processes, technology, and the environment interact. This supports us to identify deeper system factors that contribute to safety events and make meaningful, organisation-wide improvements to reduce risk and enhance the overall quality of care, staff experience, efficiency and service outcomes by improving the systems that people work in.
Barnardo’s has implemented PSIRF to ensure that our response to safety events is structured, fair, and focussed on understanding systems, not assigning blame, so that we can learn and improve together.
Our work implementing the PSIRF in 2024/25
Our initial step entailed identifying which health contracts already employed a recognised incident reporting and recording system in collaboration with a lead partner. Our research determined that certain services already operated within the PSIRF framework, reporting incidents and accidents through systems such as Datix into Learning from Patient Safety Events (LFPSE). This was predominantly observed in our partnerships, where we did not serve as the primary service provider, necessitating close collaboration with the lead organisation to ensure confidence in data gathering for oversight. The learning aspect in these relationships is always maintained by the lead organisation and Barnardo’s is committed to working in partnership and addressing all learning outcomes.
During our internal stakeholder meetings, our project manager convened experts from each field, including heads of service and business areas. This process facilitated effective communication with the appropriate departments and ensured that all current information was compiled in a structured manner.
What we're doing well
As an organisation, Barnardo’s has continuously adapted to new ways of working by embracing our trauma-responsive approach, investing in colleague development, and implementing our five-year strategy.
Throughout our planning and mapping processes, we have successfully transitioned to a more effective way of addressing incidents across the organisation. We understand that we must concentrate on learning and developing a deeper understanding to improve. That’s why Barnardo’s is committed to implementing the Patient Safety Incident Response Framework across all its services.
Within the framework of NHS contracts that Barnardo’s operates under, senior leaders have identified several safety areas of focus based on their analysis of safety and quality data; this enabled the identification of the most significant safety issues to be included in our PSIRF plan and covered within our framework PSIRF policy.
What we need to improve and develop
Following the implementation of PSIRF, our focus now turns to embedding the processes. This includes rolling out organisation-wide training to build capability and consistency, developing tailored PSIRF templates that reflect our context, and strengthening how we translate learning into tangible and measurable improvements.