Patient Safety Review Team

The Patient Safety Review team centrally support PSIRF processes and their operation within the Trust.

This is by providing specialist support and advice on PSIRF matters, managing Trust and Executive patient safety panels as part of the PSIRF oversight role and liaison regarding reviews with external stakeholders such as other providers, ICB/NHS England and the Police.

The team also provide reviewer capability to the clinical divisions working closely with a Divisional Learning Response and Family Support leads. The aim is to provide divisions with timely and robust reviews based on sound methodology to maximise learning but also support families and colleagues with a compassionate approach throughout the process. A systems-based approach is used for reviews supported, this can range from from help with terms of reference setting to production of intensive summary reports know as a Patient Safety Learning Response Reviews (or PSLRs).  Each reviewer will manage their own caseload of reviews and are supported by the Review team to achieve this. In line with the Trust Restorative Just and Learning culture the reviewers will ensure that they seek to discover contributing factors rather than apportion individual blame. This approach enhances learning and improvement, allows organisations to examine incidents openly (without fear of inappropriate sanction) and supports those involved and affected. 

The team work closely with the divisional risk and governance teams, holding weekly meetings to discuss reviews underway to ensure they are progressing satisfactorily.

The Patient Safety Review team have a specific role in ensuring that the Trust meets it’s requirement to learn from deaths by maintaining processes that support this. The reviewers will consider care and treatment prior to death by completing triage screening following a report of a death on the Radar incident reporting system. They may then complete a more in-depth review called a Structured Judgement Review where this is indicated to provide insight on an individual’s care and treatment to provide learning to the organisation. This process sits alongside and supports PSIRF processes for review of patient safety incidents that meet national or local priorities.

The Patient Safety Reviewers findings are considered during a mortality MDT organised by the Review team and clinically led by the Director of Patient Safety or a deputising Consultant Psychiatrist. Clinical teams are invited to participate where possible to discuss those cases relevant to their service area. Learning is shared with the teams and back to the division.