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Health researchers across Bradford and Leeds have played a key role in introducing a landmark change to national patient safety policy in England which offers patients and families an opportunity to be involved in investigations.

Over the past six months, researchers at the Bradford Institute for Health Research, part of Bradford Teaching Hospitals NHS Foundation Trust, have been collaborating with the national patient safety team at NHS England and Improvement, and the national independent healthcare investigations body – the Healthcare Safety Investigation Branch – on this important change.

On 16 August, a new policy was launched, called the Patient Safety Incident Response Framework. This new policy changes the way that NHS trusts will be asked to respond to patient safety events.

As part of this, new guidance has also been published which supports patients and their families to be involved in investigations that happen after something has gone wrong with care or treatment.

The Learn Together programme started in October 2019, aiming to explore and understand how patients and families are involved in healthcare investigations, and then develop and test better ways of supporting this involvement. This work is funded by the National Institute for Health and Care Research (NIHR).

In this programme, researchers spoke to over 50 patients, family members, healthcare staff, and incident investigators, to understand how investigations are done, and how to improve involvement.

The team then worked with a large community of people including patients and families, healthcare staff, policy makers and managers, to collectively design new guidance to support patients and families to be more engaged in investigations.

This work has then fed into the new national policy framework, which asks all NHS trusts in England to work differently with patients and families when carrying out investigations.

Jane O’Hara, Professor of Healthcare Quality & Safety, University of Leeds, leads this programme of research, which is based in the NIHR Yorkshire and Humber Patient Safety Translational Research Centre, at the Bradford Institute for Health Research.

She explained: “Sometimes when receiving care, things go wrong, and this can result in serious physical or psychological harm to patients. When this happens, it is really important to investigate what happened, so that NHS trusts can reduce the likelihood of them happening again.

“One of the main ways that learning can be enhanced is to involve those closest to the event – patients and families. But involving people in an investigation has not always been done consistently, and our research suggests that it is not always a straightforward process.

“Through our work, we have been able to develop new guidance that supports trusts to involve patients and families in investigations with sensitivity and compassion.”

Chief Medical Officer at Bradford Teaching Hospitals, Dr Ray Smith, said he was extremely proud of the team’s work.

“This is yet another example of how research carried out in Bradford is making its mark at a national level,” he said. “Healthcare investigations are so important in learning lessons for the future, but also for giving patients and families answers, so I’m very pleased to see them becoming more involved in this process.”

Based on the learning from the wider research programme, Dr Siobhan McHugh, Senior Research Fellow at the University of Leeds, and Jane, have worked closely with colleagues in the national patient safety team, and the Healthcare Safety Investigation Branch since the end of last year on this new policy framework.

“We are absolutely delighted that our learning from the Learn Together programme has been able to quickly inform new policy on this important issue,” added Jane.

This policy represents a draft framework that will be refined over the next year as the team gathers information and feedback from those using it. The final version will be made available in summer 2023.

Further information on PSIRF can be found on the NHS England website: