At NHS Dorset, the Patient Safety and Risk team works to improve patient and service safety and minimise risk.

The team:

  • oversees provider patient safety incidents, and how they respond to them

  • identifies themes and trends in provider incident data

  • helps providers share their learning with each other and with the rest of the country

  • supports providers with everything related to patient safety.

Patient Safety Incident Response Framework

The Patient Safety Incident Response Framework (PSIRF) sets out how the NHS responds to incidents. It focuses on understanding how incidents happen instead of looking at who is to blame. This means more effective learning for staff, and safer care for patients.

This framework replaces the Serious Incident Framework (2015) and is a key part of the NHS Patient Safety Strategy.

Based on existing local improvement work, the PSIRF can help organisations develop a patient safety incident response policy and plan. It can also help them work out where a patient safety incident response would help most.

It also removes the requirement that only ‘serious’ incidents are investigated.

This means:

  • more focus on areas with the greatest potential for improvements

  • important learning from incidents not classed as ‘serious’.

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

This document was published alongside the PSIRF. It says anyone affected by an incident (for example patients, families, and staff):

  • should be treated with compassion

  • should be involved in any investigation process.

Learn from patient safety events

A new national NHS service for recording and analysing patient safety events. It helps improve the learning gathered from patient safety incidents, making care safer.

How LFPSE will improve patient safety learning

Patient safety and risk training

NHS England has published the first NHS-wide patient safety syllabus, available to all NHS employees. It will result in better patient safety training for all staff.

The training outlines the NHS’s approach to patient safety.

Level 1 – Essentials for patient safety

All NHS staff encouraged to complete this level.

Also provides a session for senior leaders – Essentials of patient safety for boards and senior leadership teams.

Level 2 – Essentials for patient safety

For people who want to learn more about patient safety and/or access the higher levels of training.

Levels 3 and 4

Intended for people identified as patient safety specialists (PSS) at their trusts. In the future other staff working on patient safety may also be able to complete these levels.

Level 5

For patient safety experts. Ideal for innovators and leaders in this area who want to build on the skills developed in levels 3 and 4.

Medical examiners

Medical examiners are senior doctors who provide independent scrutiny of causes of death. They do this outside of their usual clinical work, and are trained in the legal and clinical elements of the death certification process.

Medical examiner system

The medical examiner system:

  • ensures independent scrutiny of all non-coronial deaths (deaths which are not reportable to a coroner)

  • ensures the appropriate direction of deaths to the coroner

  • provides a better service for the bereaved and an opportunity for them to raise any concerns to a doctor not involved in the care of the deceased

  • improve the quality of death certification

  • improve the quality of mortality data.

Medical examiner offices

In England, these are based at acute trusts (and a small number of specialist trusts). They are staffed by medical examiners, supported by medical examiner officers.

The role of these offices is to examine deaths to:

  • agree the proposed cause of death and the overall accuracy of the medical certificate of cause of death (MCCD) with the doctor completing it

  • discuss the cause of death with bereaved people and check if they have questions or concerns about care before death

  • act as a medical advice resource for the local coroner

  • identify cases for further review under local mortality arrangements

  • contribute to other clinical governance processes.

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

The Patient Safety Incident Response Framework (PSIRF) promotes greater engagement with people affected by an incident. It makes sure patients, families and staff are treated with compassion, and are part of any investigation.

Patient safety partners

I am a Pathway Coordinator for Community Action Network’s Wellbeing Collaborative, and I work with a dedicated team of hospital pathway coordinators, who support patients through the hospital discharge process.

With over 20 years of experience in the NHS in various roles, from the 999/out of hours services to outpatient administration, my real passion is meeting patients face to face & supporting them to return to the community they love.

The part of both my roles that I enjoy the most is ensuring that patients have a voice and that they are listened too.

When I’m not working, I can be found in the communal garden where I live, revamping a tired & very neglected space, making it into a colourful, exciting & welcoming place to spend my time. I’m an excellent baker & my cakes are legendary! I enjoy spending time with my husband and 6 grandchildren, ranging in age from 14 months to 17 years. In the rest of my spare time, my husband and I are busy volunteering for a local CIC (Community Interest Company) & the University Hospital Dorset Charity.

My name is Denise Wentworth and I am one of NHS Dorset’s volunteer Patient Safety Partners.

Over many years and for most of us the NHS has provided a comfortable backstop to our healthcare. Like many people I have had cause to use its services, both personally and for members of my family. I have seen its treatments expand, its use of drugs grow, and its ways of working become more complex. As a carer for several years for my late mother, I have noted how illness episodes and medical interventions with the best intentions can exert anxiety and confusion to the vulnerable, and can impact adversely on health. I saw too how valuable it was when advice and explanations were reassuring, simple and clear.

My background has been in healthcare since the ’70’s. I have worked as a Nurse in a variety of specialties in the NHS and, since 2003 as a nurse practitioner in both A&E and general practice. I hope I was able to provide the good quality service that I would have liked and given that extra time to those that needed it. In the busy melee of work there is little time to view your service from the perspectives of others. It has been a career that I loved but it also gave me the realities of providing healthcare in ever-changing and, in sometimes challenging times.

Separate to this career and during a career break early on to raise children, I helped for a short period to set up a business with my husband. It was a time fraught with money concerns, of negotiating quickly how to run a business and of long hours. When I returned to nursing I realised this was a valuable experience in understanding the pressures on some families managing such a way of life without regular income, little time to access appointments or to look after their health.

Now retired and without caring responsibilities, I am part of a committee that help support, hire out and maintain our village hall as a charity for the community. This gives a much-needed point of connection for villagers to meet up, have fun and learn new things.

I am also treasurer of a local NHS retirement fellowship where, apart from catching up with old and new colleagues, we hear talks from people whose careers and adventures have taken them in many varied and interesting directions. Both these pursuits put me in a position to have a good natter and invariably hear about other’s health experiences!

On seeing the advert for a Patient Safety Partner (PSP), I felt that I would very much like to contribute. It is an exciting time to be part of a well organised drive and focus on patient safety and since meeting enthusiastic members of the patient safety team and being made to feel welcome, I feel even more keen to play a part.

In coordinating this role and integrating me into the team, Jaydee Swarbrick, the Patient Safety Lead for Dorset, has provided me with regular supportive meetings. By answering my questions and listening to my views I have felt a valued member and, by including me on the Patient Safety Incident Response framework (PSIRF) workshop update, I have gained a greater understanding.

I have now attended both the Oversight and Shared Learning Panel and the place-based meetings. The general theme to these are to learn from the patient safety events presented and from those filtered down from NHS England. As important, is to then share this learning. Care is taken to ensure that everyone who has been involved in these events are well supported. I have also attended the medicines quality and safety meeting, with an agenda focused on the safe use of medicines considered from many perspectives. Here, systems or methods of medicine use that may cause harm are discussed and ways of working to mitigate risk are planned. Again, I have been made to feel a welcome member and at present have been absorbing the processes whilst learning who everyone is and what role they have to play.

Backing up this role, I have been introduced to the Patient Safety Partner network for South West England. In these quarterly meetings, ideas and ways of working are shared with other PSPs from a variety of backgrounds involved in many areas of the NHS. In addition, I have been introduced to a national safety partner bulletin, produced regularly by PSPs giving much PSIRF information. Usefully it has given examples of integrating the role, the impact the role might have, issues around measuring improvements to safety and what it means to be patient centred.

It is early days but as I learn more, I am finding that this open, supportive process with a strong focus on learning from these safety events, is a positive direction for users of the NHS and staff alike. I continue to look forward to learning more and ensuring my contribution is always patient focused.

Responding to patient safety incidents

Valerie’s story

This video is part of a series of patient story videos produced as training resources for the NHS. It demonstrates the impact the initial response to a patient safety incident and subsequent investigation has on the patient.

In this video 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.

Kathryn’s story

Kathryn recalls her personal experience of temporary paralysis and respiratory arrest after residual anaesthetic drugs were not flushed from her lines and cannula following surgery.

Just culture

The fair treatment of staff supports a culture of fairness, openness and learning in the NHS. It helps staff feel confident to speak up when things go wrong, rather than fear blame. Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented in the future.

Work is being done at NHS Dorset around psychological safety and the Freedom to Speak Up agenda.