Recommendation BRIS-109: Create single, unified system for reporting and analysing sentinel events

The Thirlwall Inquiry has noted action taken in response to this recommendation.

The Patient Safety Incident Response Framework or ‘PSIRF’ (2024) (which replaced the Serious Incident Framework from April 2024) is the framework used by the NHS to develop and maintain effective systems and processes for responding to patient safety incidents.

Since 2004 the NHS has operated a comprehensive national patient safety incident reporting system, initially the National Reporting and Learning System (NRLS) and now the Learn From Patient Safety Events (LFPSE) serviceLFPSE is new national NHS system for the recording and analysis of patient safety events that occur in healthcare.

All reported provider patient safety incident records are collected by LFPSE and the data is available to ICBs and NHS England. Provider incident responses should be consistent with the PSIRF. PSIRF is a requirement under the NHS Standard Contract (from 1 April 2024) and puts a strong focus on compassionate engagement and involvement of those affected by patient safety incidents, including patients, families and staff. Guidance on PSIRF is available.