Engaging and involving patients, families and staff following a patient safety incident

Under the Patient Safety Incident Response Framework (PSIRF) there will be greater engagement with those affected by an incident, including patients, families and staff. Ensuring they are treated with compassion and able to be part of any investigation.


Guide to engaging and involving patients, families and staff following a patient safety incident

The ‘Guide to engaging and involving patients, families and staff following a patient safety incident’, published alongside PSIRF, sets out expectations for how organisations should engage with all those affected by patient safety incidents. Organisations should work hard to answer any questions and to involve those affected in patient safety incident investigations.

This guidance has been published in partnership with the Healthcare Safety Investigation Branch (HSIB) and Learn Together.

This guidance is based on the available evidence at the time of publication and it will be evaluated over the coming year using an independent national survey undertaken by the Learn Together research team. To express interest in taking part in the survey contact: patientsafety.enquiries@nhs.net.

The survey findings will be combined with the Learn Together programme’s broader evaluation, to inform the next iteration of this guidance and is expected to be published in 2024.


You can also listen to our podcast which introduces the guide, discusses how it was developed, and future plans in this area of work. The podcast features Tracey Herlihey, Head of Patient Safety Incident Response Policy and Lauren Mosley, Head of Patient Safety Implementation, both from the NHS England National Patient Safety Team; Louise Pye, Head of Family Engagement, at HSIB; and Jane O’Hara, from the Learn Together research team, who is a Professor of Healthcare Quality and Safety, University of Leeds and Deputy Director of the Yorkshire Quality and Safety Research Group.

Additional resources

Learn Together have produced draft versions of specific guidance for investigators to guide engagement and involvement activity, as well as a guidance booklet aimed at supporting any healthcare staff involved in the investigation. NHS organisations can download and use these resources in their responses to patient safety incidents.

The resources include:

  • Patient/family information
  • Investigator guidance
  • Staff information
  • Investigation record

The resources are being tested as part of the Learn Together research programme and feedback will inform final versions, to be published alongside the updated PSIRF engagement guidance in 2024.

You can also download a single page overview summary of Part A – Creating the right foundations and Part B – Engagement and involvement process – from the ‘Guide to engaging and involving patients, families and staff following a patient safety incident’.

Comments from our early adopters

“This guide is a useful resource for staff seeking to support engagement and involvement of all those affected by patient safety incidents. The guide acknowledges that there will not be a simple ‘one size fits all’ approach. Instead, it explores the various options which can support engagement and involvement and offers suggestions on how these can be put into practice. I think this will be a key resource for those involved in learning from patient safety incidents, and I will be using it to support my practice in future.” 

Megan Pontin, Patient Safety Incident Investigator, West Suffolk NHS Foundation Trust


“There is no one-size-fits-all-approach to support the patient and staff in response to a patient safety incident. Adapting to each situation and varying our approach to engagement and learning can be challenging in healthcare. That is why this guidance is crucial to equipping us with tools and knowledge to how we harness insight and involve the patient, as well as our staff across the NHS system, when a patient safety incident occurs.” 

Nicholas Seaton, Patient Safety Manager, North Bristol NHS Trust

Patient story videos

These patient story videos demonstrate the impact the initial response to a patient safety incident and subsequent investigation can have on patients.

Kathryn’s story

Kathryn talks about her experience following an incident where she was harmed when her cannula was not flushed following surgery, leaving her close to death and temporarily paralysed. She describes how openness and having the opportunity to be part of the solution meant that the investigation process didn’t exacerbate the trauma of the event.

Kirsty’s story

Kirsty talks about her experience following an incident where there were problems with care during the delivery of her third child following the administration of a Syntocinon drip. Kirsty describes the investigation process as being clouded in mystery and feeling like the organisation put her into a victim box without any concern for her mental state.

Valerie’s story

Valerie, a patient with Parkinson’s disease, talks about her experience following an incident where she was mixed up with another patient and given the wrong medication. Valerie describes how she didn’t want to complain, she was used to getting excellent treatment from the NHS, but the handling of the response left her ‘hopping mad’ with no choice.