PSIRF and Coroners: Can the NHS Balance Learning and Legal Accountability?

I was scrolling through LinkedIn the other day and stumbled upon a post by one of my connections. It referenced a recent article in the Health Service Journal that has reignited the debate about the tension between NHS trusts adopting the Patient Safety Incident Response Framework (PSIRF) and the expectations of coroners at inquests. The article mentioned that several trusts are running Root Cause Analyses (RCAs) alongside PSIRF investigations-not for internal learning, but to meet coronial demands.

This really struck a chord with me. Over the past few years, I've had countless conversations while delivering our PSIRF training and during our Roundtable events. Reading the replies and having subsequent conversations with some trusts and those involved in patient safety, it became clear that there's a critical concern: Can the NHS fully embrace a modern, learning-oriented approach to safety while still meeting the traditional evidentiary needs of the Coroner’s Court?

Two Different Worlds

PSIRF marks a significant shift away from the reactive, blame-oriented culture of the past. Grounded in the Systems Engineering Initiative for Patient Safety (SEIPS), it encourages a broader view of incidents—considering systems, context, and environment alongside human actions. It prioritises proportionality, learning, and compassion for both staff and families. It's not about investigating every death, but about identifying cases with the potential for systemic learning.

On the other hand, coroners focus on facts: what happened, when, and who was involved. They seek clear timelines, specific actions, and demonstrable change - often in a format that looks remarkably similar to a traditional RCA. 

As one contributor in the LinkedIn discussion put it: "Perhaps it’s the coroners that need to adapt their approach... rather than rely on being handed everything on a plate RCA-style."

But it's not that simple.

Where PSIRF Meets the Coroner’s Court

The coronial process, though non-adversarial, can feel intensely scrutinising. From conversations during oversight courses and more general discussions, I've always felt that the coronial process can have a huge emotional impact - fear, anxiety, defensiveness - all of which can undo the psychological safety PSIRF aims to foster. If a safety concern arises during an inquest, witnesses often experience it as a personal interrogation.

This isn't about who's right. It's a call for alignment.

Many contributors to the LinkedIn thread shared stories of productive engagement with their local coroners, including early communication, transparency about PSIRF methodology, and sharing Structured Judgement Reviews (SJRs) or Learning From Deaths (LfD) outcomes instead of full investigations. These proactive approaches have helped build mutual understanding and, crucially, trust.

"We haven’t had this issue… we engaged with them early, explained PSIRF, and sent them our templates," said one patient safety lead. "We’ve had positive feedback on our responses."

Another added: "We had to do some awareness work with our HMC, and they’ve slowly adapted well to PSIRF reports."

But others highlighted the friction that arises when no investigation is done at all - a situation PSIRF allows for, but which can appear, to grieving families and coroners alike, as a lack of diligence or transparency.

What Good Looks Like

The emerging consensus? Success lies not in choosing PSIRF or RCA, but in intelligently adapting how PSIRF is applied, documented, and communicated.

When PSIRF is done well - with compassionate engagement, thoughtful sequencing, assigned actions, and ongoing oversight - many feel it more than satisfies the coroner's requirements. 

One contributor summarised this powerfully: "A detailed level of scrutiny plus clear safety actions, dated and assigned to a responsible individual, provides assurance that the learning responses have been robust and the organisation’s intent is both engagement and learning."

Others pointed out the importance of maintaining consistency in tone and language throughout the learning response journey. Despite best intentions, the old blame-based narrative can creep back in through clinical reviewer comments or poorly structured findings.

"By the time findings are shared more widely, the narrative may have come full circle - returning to the very language and approach that we’ve worked for decades to move away from."

Towards a Shared Future

As PSIRF beds in, and as understanding grows across clinical, governance, legal, and coronial systems, there is cautious optimism. Legal teams, inquest officers, and even some coroners are beginning to attend PSIRF and Just Culture training.

This shows a shift - a recognition that collaborative, system-based learning is not incompatible with coronial scrutiny. In fact, when done well, it may offer a more honest and sustainable route to preventing future harm.

But for now, dual accountability remains a reality. NHS trusts must continue to balance two mandates: embedding PSIRF principles that move us towards a safer, fairer future, and satisfying the still-traditional expectations of coroners and families in the present.

As one contributor wisely noted: "PSIRF is new, its principles are welcome - but there is an older world beyond hospitals that is still adapting to it."

Key Takeaways

• Early engagement with coroners and legal teams helps prevent misalignment later.

• Transparent communication about when and why cases are (or are not) reviewed under PSIRF is critical.

• Consistency in tone and language within reports supports a blame-free culture.

• Structured Judgement Reviews (SJRs) and well-documented Learning Responses can often meet coronial standards.

Collaboration across functions - clinical, legal, governance, and family liaison - is essential to embed PSIRF meaningfully.