What to expect and how you can be involved
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Scan the QR code or go to https://www.geh.nhs.uk/patients-and-
visitors/patients/patient-leaflets/patient-safety-incident-investigation to find all the information and links to make the process more simple and more relevant to you.
Different Stages of the Patient Safety Incident Investigation
Step 1 - Understanding you and your needs
We are sorry to hear that you, a family member, or a loved one has been involved in a patient safety incident whilst under our care. It is important to us that we listen, understand and learn from your experience. The incident will be looked into as part of a Patient Safety Incident Investigation (PSII). This booklet gives you information about the process and how you can take part if you would like to.
We understand that the investigation cannot alter the events in your case, but the primary goal of the review is to work with you to understand what happened, so we can learn how things can be changed and improved to reduce the chances of it happening again.
The George Eliot Hospital NHS Trust is committed to learning, improving and making positive changes. Your involvement in this process matters to us because it helps us work together to create safer, better care.
The definition of a patient safety incident is:
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Unintended or unexpected incidents which could have or did lead to harm for one or more patient’s receiving healthcare. Patient Safety Incident Response Framework (PSIRF)
PSIRF is a framework followed by all NHS Trusts in England in how to identify, and respond to patient safety incidents |
Not every patient safety incident needs an investigation. Sometimes, a different way of learning, like a quick team debrief or after action review can be more helpful.
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If you would like to read more about PSIRF, you can find it here: https:// |
A patient safety incident investigation is to find out what happened and why, so that we can try and reduce the chances of it happening again.
We will look at what happened in the incident, and review procedures, practices or areas to better understand how these may have influenced one another. This will allow us to identify areas that need to be changed or improved. The purpose of this process is not to blame the individuals involved but to listen, learn and make improvements. Everyone involved will be treated respectfully and with compassion.
Step 2 - What to expect
As soon as possible after being aware of the incident, you should be informed that the incident has happened and be provided with an apology. This is called Duty of Candour and is required by law by all Trusts to ensure they are open and honest when things have not gone as planned.
For further information on the duty of candour please visit the Care Quality Commission (CQC) website at: https://
Once the Trust has identified that a patient safety incident investigation is needed, a lead investigator will be appointed. This person will be a trained member of staff who will lead the investigation, who was not involved in the care.
You will be contacted either by the investigation lead or an allocated main point of contact. They will introduce themselves, talk to you about the incident and the investigation process.
They will ask you about what support you need and your preferences about how you and the main contact will work together, this will include things like how and when you would like to be contacted.
You will be provided with their contact details, and they can arrange for you to share your experience and provide any questions or concerns that you would like answered as part of the investigation. They will keep you informed of progress and timescales as you prefer.
Here is a list of ways you can get involved that will be offered by your point of contact:
- Receive further information about the investigation
- To share experience of the incident
- To ask any questions that you would like looked at in the investigation
- To see a copy of the draft report
- To see a copy of the final report
- The opportunity to discuss the final report
Step 3 - Agreeing what the investigation will include
The lead investigator will decide on the scale and scope of the investigation. The scale of the investigation depends on how complex the incident is and if there are more than one incident being reviewed as part of the investigation. In some cases, there may be more than one of the same incident and these will be investigated together.
The scope of the investigation is when the ‘Terms of Reference’ are set. These act as a guide for those involved in the investigation so they know what will be included and what questions need to be answered. You will be offered the opportunity to review and add to the terms of reference by your point of contact. If any of your questions are outside the scope of the investigation, you will be informed why and directed to the right people to answer them for you. You are welcome to bring someone you trust with you or we can help you find an advocate. We can provide information in different formats such as easy read or large type and in different languages.
The lead investigator will gather relevant information to answer the ‘Terms of Reference’. This information will be used to understand exactly what happened and may include:
- Medical notes (electronic / paper)
- Trust policies and guidelines
- National policies and guidelines
- Verbal or written accounts from people who experienced the incident
- Visits to ward or area where incident occurred
From identifying a clear picture of what happened, we can explore all the different factors that may have contributed to the incident. A systems-based method of investigation will be used to identify areas that need to be changed or improved. An action plan will be created from our findings to prevent or reduce the chances of it happening again. Specialists will form part of an investigation panel supporting the lead investigator in reviewing the information by giving their knowledge which is relevant to the investigation.
Step 4 - Checking and finalising the report
Once the lead investigator has written the first draft, they will send it to an investigation panel for review and relevant area/service leads to ensure the information is accurate and actions are achievable. Your point of contact will ask if you would like to see the report and check the information is correct. We can provide you with a draft report or sections of the report and give you time to check the report for accuracy. The final report will be taken to our Clinical Improvement Group (CIG) for approval.
Step 5 - Next steps
At the end of the investigation, you will be offered the final report which provides the findings and conclusion of the investigation. We understand this may be a difficult time for you. We will offer you a meeting with the lead investigator to discuss what they found in the investigation, and how they decided on their actions. You will have the opportunity to ask any questions you may have. They will also talk though any support you might need moving forward and can help arrange this for you.
If the lead investigator knows there is going to be another investigation alongside or immediately after this one, they will tell you. For example, following an unexplained death there will be an inquest led by the coroner, or it may be directed to a Medical Examiner. They will also support you to find out more information about the additional investigation process if you would like to know more.
Once the investigation process is complete, we need to start implementing the action plan included in the report. Coventry and Warwickshire Integrated Care Board (ICB) monitors actions from the report to ensure we complete them within the specific timescales. You may be able to get involved in sharing your experience to drive these improvements. Please discuss with your point of contact if this is something you would be interested in.
Hopefully, you will be assured by the investigation outcome. Your valuable involvement will help to reduce the risk of the same thing happening again.
If you are unhappy with the investigation speak to your main point of contact in the first instance, to see if the problem can be resolved.
The investigation should have answered most if not all of your questions. If you still have questions that were not able to be answered, then please inform your point of contact who will provide you with the details of relevant departments or organisation that can help.
Mind is a registered charity who provide support and advice to anyone who is suffering 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. You can find general support resources and information about local services at https:/
Bereavement care is a free services designed to help and support people struggling to deal with bereavement. If you have been affected by a bereavement, you can find more information at: www.
Citizens Advice can give high quality, independent advice about any problems or questions you might have. They can provide you with the knowledge and confidence to find a way forward. They have a network of national and local independent charities that can provide free and confidential advice. You can find out more at https:/
This booklet was brought to you by the Patient Safety Team at George Eliot Hospital NHS Trust.
If you have any further questions, please contact the team on 02476 865244. Or email geh.patientsafety@nhs.net
George Eliot Hospital is a smoke free environment. For help and advice to stop smoking you can call the national helpline on 030 123 1044 or visit https://
The Trust has access to interpreting and translation services. If you need this information in another language or format please contact 024 7686 5550 and we will do our best to meet your needs.
If you would like to provide feedback on this booklet please 
scan the QR code and complete the form or access the form at https://
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