Abstract

Background: In England’s National Health Service (NHS), the Patient Safety Incident Response Framework (PSIRF) replaced prescriptive serious-incident thresholds with locally planned, considered and proportionate responses focused on learning and improvement. National guidance identifies important considerations, while local NHS organisations have developed decision meetings, flowcharts and matrices. However, implementation evidence and a 2025 report from the Health Services Safety Investigations Body indicate continuing uncertainty and variation in the practical selection of learning responses. Aim: To propose PSIRF-SELECT, a structured qualitative deliberation and documentation aid for use at the point where an NHS provider decides whether, why and how to undertake a learning response. Development: A targeted search and narrative synthesis of publicly accessible official guidance, peer-reviewed literature, international frameworks and local NHS tools was undertaken on 14 August 2026 and updated on 22 August 2026. The purpose was to identify existing decision support, examine whether the proposed operational gap was credible and derive candidate domains for the framework. This was not a systematic, scoping or rapid review. Candidate domains were compared with national requirements and relevant literature on systems thinking, involvement, outcome bias and investigation quality. Framework: SELECT comprises six domains: Specified requirements and immediate safety; Existing knowledge, evidence and improvement activity; Learning questions and potential; Engagement and equity; Context, complexity, capacity and coordination; and Type, transparent rationale and triggers for reconsideration. The word SELECT naturally contains two E positions: the first E concerns existing knowledge and improvement, while the second E concerns engagement and equity. The full domain names are used throughout to prevent ambiguity. Each domain is answered in words, not points. The output is a human-approved response with documented alternatives, uncertainties, engagement commitments and review triggers; no score or automatic recommendation is generated. Illustration and Evaluation: Three wholly synthetic cases demonstrate different outcomes: a patient safety incident investigation, a thematic review and no additional individual learning response beyond recording, engagement and monitored improvement. Co-design, feasibility testing and prospective multi-site validation are required before claims of effectiveness or routine adoption. Conclusion: PSIRF-SELECT offers a testable way to operationalise and make visible the reasoning already expected by PSIRF. Its contribution is integration, transparency and evaluability rather than replacement of existing guidance or judgement.

Keywords

Patient Safety, Patient Safety Incident Response Framework, PSIRF, National Health Service, NHS, England, Incident Response, Learning Response, Systems Thinking, Decision Support, Patient Involvement, Quality Improvement

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1. Introduction

Patient safety incident response has two distinct challenges: deciding what form of learning response is proportionate, and then conducting that response well. PSIRF addresses both by replacing the previous Serious Incident Framework with a system that prioritises compassionate engagement, system-based learning, considered and proportionate responses, and supportive oversight [1]-[4]. The change is intentionally important: severity of outcome alone is an unreliable proxy for learning value, while exhaustive investigation of every event can consume capacity without generating additional knowledge or improvement.

Flexibility, however, transfers responsibility to local decision-makers. They must interpret national requirements, their patient safety incident response plan (PSIRP), current intelligence, the needs of people affected, existing improvement work, the learning question, available expertise and cross-system dependencies. They must also explain why one response was chosen and another was not. A defensible decision therefore requires more than a flowchart endpoint; it requires a visible reasoning process.

This paper proposes PSIRF-SELECT as a structured deliberation and documentation aid. It is deliberately positioned inside PSIRF rather than as an alternative to it. SELECT is intended to help a multidisciplinary group organise and record the considerations already distributed across national guidance, local tools and patient-safety evidence. It is not a diagnostic test, risk score or algorithm. It does not decide whether an incident is blameworthy, does not direct employment or professional-regulatory action and does not merge external statutory processes with local learning.

1.1. Aim and Research Question

The paper asks: Can a concise six-domain framework make the selection of a proportionate PSIRF learning response more transparent, consistent and evaluable without recreating rigid thresholds or displacing professional judgement?

The immediate aim is conceptual: define the framework, show where it fits, test it against synthetic cases and specify a responsible evaluation programme. Claims about reliability, validity, usability, efficiency, equity or safety impact are reserved for later empirical work.

1.2. Claimed Contribution

In the public sources reviewed, the author did not identify an openly available, nationally standardised and empirically validated point-of-decision instrument that integrates the key considerations and records the rationale for choosing among PSIRF learning responses. This statement is deliberately narrower than claiming that no decision tool exists.

Local NHS flowcharts, decision meetings and FutureNHS resources already exist and are important counterevidence to any “first tool” claim [5]-[10]. SELECT therefore claims potential value in integration and documentation: it makes engagement and equity explicit, defines the learning question, records alternatives and uncertainty, separates parallel routes, and creates a minimum dataset that can be audited and validated.

2. The English PSIRF Context and the Selection Problem

2.1. What PSIRF Requires

PSIRF is the NHS approach to developing and maintaining effective systems and processes for responding to patient safety incidents for learning and improvement [1]. It applies contractually to services delivered under the NHS Standard Contract, with additional guidance for application outside NHS Trusts and in primary care contexts [1] [11]. Providers are expected to maintain a patient safety incident response policy and a PSIRP based on their incident profile, stakeholder engagement and improvement priorities [2] [3].

The guide to proportionate response establishes a sequence rather than a severity threshold [2]. Nationally specified responses and applicable external requirements are considered first. Locally, the organisation considers its PSIRP, the circumstances and needs of those affected, what is already known, current improvement activity and whether a response is likely to generate new learning. It may select a patient safety incident investigation (PSII), after action review (AAR), multidisciplinary team (MDT) review, swarm huddle, thematic review or another suitable system-based approach [2] [4]. When a risk is understood and effective improvement is active and monitored, an additional individual learning response may not be proportionate—provided the event is still recorded and those affected are engaged appropriately [2].

2.2. Why Selection Remains Difficult

The selection task is a form of structured judgement under uncertainty. Information may be incomplete; harm outcome can bias perceptions of culpability; the most visible event may not represent the most important system risk; patient and family questions may differ from the organisation’s initial learning question; and cross-organisational dependencies may be outside the decision panel’s authority. Resource constraints matter but must not be disguised as a lack of learning potential.

HSSIB’s 2025 examination of investigation under PSIRF reported uncertainty and variation in practical application and specifically invited NHS England to provide practical steps for selecting the most appropriate learning response so organisations can adopt a robust, standard approach [12]. This is direct evidence of an operational need, but it is not evidence that no tools exist or that a new framework will be effective.

The NIHR-funded RESPONSE study provides additional evidence that implementation and impact of the changing English incident-response system remain active research questions [13].

Empirical literature strengthens the rationale for transparent deliberation. A rapid review of the English NHS before PSIRF found investigation, learning and relational challenges [14]. Studies of systems-based practice and investigation reports show continuing difficulty moving from linear explanations to systems thinking [15]-[18]. Experimental evidence demonstrates outcome bias in judgements of culpability and punitive recommendations [19]. Policy and qualitative research show variability in involvement and the potential for post-incident processes to compound harm [20]-[22]. Together, these findings support explicit prompts, diverse participation and a recorded reasoning chain; they do not validate a particular selector.

International guidance and established patient-safety literature also support systems-oriented learning, caution against simplistic root-cause explanations and emphasise the relationship between analysis and improvement [23]-[28].

2.3. Existing Provision and the Residual Gap

The national guide and standards supply the substantive considerations [2] [3], while the learning-response toolkit supplies methods [4]. Public local documents show that NHS organisations have operationalised selection through flowcharts, rapid review and decision meetings. Examples include Great Western Hospitals, University Hospitals Dorset, Kent and Medway, York and Scarborough, and South West Yorkshire Partnership [5]-[9]. A FutureNHS decision-making flowchart has also been referenced in BMJ International Forum material [10].

Table 1 distinguishes the support already available from the narrower residual question that PSIRF-SELECT is intended to address. It shows why the proposal should be framed as an integrated minimum reasoning record, not as the first decision tool.

Table 1. Existing PSIRF decision support and the residual operational question.

Note: PSIRF, Patient Safety Incident Response Framework; PSIRP, Patient Safety Incident Response Plan.

The residual gap is therefore not the absence of any decision support. It is the lack identified in the reviewed public literature of a common, validated, minimum deliberation-and-documentation structure that integrates the full set of considerations and makes the decision reviewable. SELECT is one hypothesis for filling that gap.

3. Conceptual Development Method

3.1. Targeted Literature and Policy Review

To inform framework development, a targeted search and narrative synthesis of peer-reviewed literature, official national guidance and publicly available local PSIRF tools was undertaken on 14 August 2026 and updated on 22 August 2026. The purpose was to identify existing decision-support approaches, examine whether the proposed operational gap was credible and derive candidate domains for SELECT. Sources included NHS England and HSSIB webpages and documents; PubMed and publisher pages using exact and broader combinations of PSIRF, incident investigation, learning response, systems thinking, selection, proportionate response, engagement and outcome bias; public NHS Trust websites; and international incident-analysis resources. Exact-name searching for “PSIRF-SELECT” was also conducted. Citation details and source-by-source implications are provided in Supplementary Table S1, which maps each source to the SELECT domain(s) or design principle(s) it informed.

Sources were included when they: 1) defined a national requirement or organisational role; 2) provided direct evidence about PSIRF implementation or learning-response selection; 3) offered empirical or conceptual evidence relevant to system analysis, involvement, bias, proportionality or investigation quality; or 4) demonstrated an existing local selection tool. No date restriction was imposed for foundational systems literature. Official and primary sources were preferred.

This targeted review was designed to inform the development of PSIRF-SELECT and was not intended to constitute a systematic or scoping review of the complete evidence base. A future formal evidence review could extend this work through a reproducible database search, broader database coverage, citation tracking and independent screening.

3.2. Framework Synthesis

Candidate decision elements were first extracted from national PSIRF requirements. They were then grouped by the practical question a decision panel must answer. The groupings were tested against four safeguards from the literature: system orientation, engagement of those affected, resistance to outcome-driven and individual-blame bias, and transparent reasoning. Finally, the domains were compared with publicly available local tools to remove any claim of being the first flowchart and to identify the proposed added elements.

The resulting mnemonic was refined to preserve six distinct functions without turning them into a numerical score. Because SELECT contains two E positions, the first is always written as “E—Existing knowledge, evidence and improvement activity” and the second as “E—Engagement and equity”. Engagement and equity are informed by national inequalities guidance [29]. The “C” domain explicitly includes capacity and coordination so lack of expertise or cross-system authority is visible rather than silently determining the outcome. The “T” domain requires the response type, rationale, alternatives, uncertainty and reconsideration triggers.

OpenAI ChatGPT (web application; accessed August-September 2026) was used during manuscript preparation as an assistive tool for evidence organisation, drafting support, language editing and document formatting. The author reviewed the resulting source selection, interpretations and framework content, made the final decisions and accepts responsibility for the manuscript.

3.3. Design Principles

• Fidelity: every domain should be traceable to PSIRF guidance or relevant patient-safety evidence.

• Human authority: the framework structures discussion; an authorised multidisciplinary group owns the decision.

• No arithmetic: domains are not weighted or totalled, and there is no cut-off for a PSII.

• Proportional information: gather enough information to choose a response, not a hidden investigation before the investigation.

• Visible uncertainty: a preliminary assessment and later reconsideration are legitimate outcomes.

• Engagement before closure: questions and needs of those affected are inputs to selection, not an optional activity after the decision.

• Separation of purposes: PSIRF learning is coordinated with, but not merged into, regulatory, employment, professional, coronial, complaints, claims or criminal processes.

• Evaluability: the minimum decision record should enable audit of consistency, process quality, equity and outcomes.

4. The Proposed PSIRF-SELECT Framework

4.1. Intended Users, Timing and Unit of Decision

The intended users are provider patient-safety teams, clinical/service representatives, improvement specialists, engagement leads and Patient Safety Partners or other patient representatives within the organisation’s authorised response-selection governance. ICB or partner-organisation participation is added when the system boundary crosses organisations. The decision unit may be a single event, a cluster, a safety issue identified from broader intelligence or an emerging risk—not necessarily an incident with severe harm.

Minimum functional composition. SELECT does not prescribe fixed job titles, a universal quorum or a majority-voting rule. The record must, however, show proportionate coverage of five functions: 1) an authorised patient-safety/PSIRF decision lead; 2) a relevant clinical or operational perspective; 3) learning-response or systems/human-factors expertise; 4) improvement expertise able to assess current controls and measurement; and 5) an engagement and patient/public perspective. One person may cover more than one function where competence and conflicts are addressed. Direct patient or family input is distinct from general patient/public representation.

Unavailable or triggered perspectives. A patient/public, cross-organisational or independent perspective may be obtained through a trained alternate, documented asynchronous input or a specifically invited contributor. Cross-organisational and independent input are required when the decision boundary or conflict assessment triggers them, rather than as standing membership for every decision. If a material perspective cannot be obtained without unsafe or disproportionate delay, the initial decision is recorded as provisional with the reason, responsible contact/escalation owner and a defined reconsideration trigger.

Approval rule. Final approval remains with the accountable person or group authorised by the provider’s published local governance. Approval requires confirmation that Gate 0 and all six domains have been considered; relevant perspectives, conflicts and capacity constraints are recorded; plausible local alternatives have been compared where choice remains; and an owner, communication commitment, review date and triggers are specified. Consensus should be sought. Where it is not achieved, the accountable approver records the dissent and the reason for the final decision. SELECT does not override the provider’s scheme of delegation.

SELECT begins after immediate clinical care, urgent risk control and initial recording have started. It is used before a learning response is commissioned, or when new information requires an earlier decision to be reconsidered. It can be applied in a meeting or asynchronously, but the final record should identify who participated and who approved the decision.

4.2. Gate 0: Actions That Must Not Wait

Gate 0 is not optional. Before deliberating about learning method, protect patients, meet immediate clinical needs, preserve relevant information, record the event, begin compassionate communication, consider Duty of Candour and identify any nationally specified or external notification/investigation route. SELECT cannot be used to delay or avoid these actions.

A nationally specified response determines the required component and is recorded with its owner; it is not treated as one discretionary option among local methods. The panel then considers whether that response alone addresses the provider’s distinct local learning questions or whether complementary local learning, coordination or improvement activity is also necessary. Any additional local response must add a defined purpose and avoid duplicating the nationally specified work. Other external routes may influence timing, information sharing, independence or scope, but they do not remove the need to record residual local actions. Where facts are insufficient to complete the gate safely, the correct decision is a time-limited preliminary assessment with named questions and a review date.

4.3. The Six Domains

Reading order is important: S, E (Existing), L, E (Engagement), C and T. The two E domains are different. They are distinguished by their full names rather than by numbered labels, because numbers could be mistaken for scores or levels.

Table 2 defines each domain, the core question it asks and the minimum information expected in a SELECT record. Together, the domains combine non-negotiable requirements, existing evidence, learning potential, engagement and equity, operational context and the final rationale.

Table 2. PSIRF-SELECT domains, core questions and minimum content.

Note: PSII, Patient Safety Incident Investigation; PSIRP, Patient Safety Incident Response Plan; CQC, Care Quality Commission; ICB, Integrated Care Board; MHRA, Medicines and Healthcare products Regulatory Agency; MNSI, Maternity and Newborn Safety Investigations.

4.4. How SELECT Is Used: Structured Narrative, Not Scoring

The proposed workflow places SELECT after immediate safety and mandatory-route screening but before a learning response is commissioned. The final choice remains a human governance decision and is revisited when defined triggers occur. The wider incident-response sequence is described in Section 6.

SELECT is a structured qualitative deliberation, not a scoring system. Each domain is answered in a short factual narrative using the information available at the decision point. The domains are not assigned points, weights or red/amber/green ratings. No total is calculated and no numerical threshold automatically requires or excludes a PSII. This design avoids false precision and preserves PSIRF’s requirement for contextual, proportionate judgement.

Table 3 translates this principle into required practice and explicit prohibitions. Its central safeguard is that completing a form structures the evidence and rationale but cannot itself validate or authorise the decision.

Table 3. Operational rules for qualitative use of PSIRF-SELECT.

The framework is completed in two passes. The first pass identifies non-negotiables, information gaps and people who must be involved. The second pass compares plausible response types against the stated learning question, engagement commitments, system boundary and current improvement. A response is proportionate when it is sufficient to answer the important question and support improvement without unnecessary delay, burden or duplication.

When direct involvement is not available before the initial decision. Communication or access barriers must prompt reasonable support—such as interpretation, translation, accessible formats or an advocate—rather than be treated as a refusal. The record states contact attempts, the reason direct involvement is declined, delayed or not yet possible, any known questions or preferences, and whether views among family members differ. It must not assume that one family view represents all those affected. When an initial decision cannot reasonably wait, it is explicitly provisional, with a named owner and date for renewed contact and a trigger to reconsider the response if later engagement adds a material question or changes the appropriate scope.

When capacity prevents the preferred response. The record states: 1) the preferred response and why it was judged appropriate; 2) the unmet capability or capacity; 3) the accountable person or body to whom the constraint was escalated; 4) the interim safety or learning mitigation; and 5) the response/review date and trigger. If a different response is used, the residual risk, the person accepting it and the reconsideration condition are recorded. A capacity constraint must not be relabelled as low learning potential.

1) Confirm Gate 0 and list parallel routes, urgent controls and responsible owners.

2) Define the unit of decision: single event, cluster, safety issue or emerging risk.

3) Complete all six SELECT domains using the minimum necessary information.

4) Where local choice remains, compare at least two plausible local responses. When a nationally specified response applies, record that required component first and then determine whether a complementary local response has a distinct justification; do not add a second response merely to complete SELECT. Use a preliminary assessment when material information is insufficient.

5) Conduct an authorised multidisciplinary deliberation, actively inviting patient/public and cross-system perspectives where relevant.

6) Record the selected response, rejected alternatives, evidence, uncertainty, dissent, owner, approver, engagement plan and review triggers.

7) Communicate the decision to those affected, commission the work and revisit when a trigger occurs.

4.5. Candidate Outputs

Table 4 lists candidate outputs that may follow SELECT deliberation. These are options rather than a hierarchy: the appropriate response is the one that best addresses the stated learning question, system boundary and engagement needs while avoiding unnecessary duplication.

Table 4. Candidate learning-response outputs and safeguards.

Note. AAR, After Action Review; ICB, Integrated Care Board; MDT, multidisciplinary team; PSII, Patient Safety Incident Investigation.

4.6. Minimum Decision Record

A completed SELECT record should be concise enough for operational use and rich enough for later review. The proposed minimum dataset is listed below; the complete reporting checklist is provided in Appendix B (Table B1). Appendix C (Table C1) shows the principal source or design basis for each proposed protected-core field.

• event/cluster/safety-issue identifier and decision date;

• immediate actions and parallel routes, with owners;

• participants, roles, conflicts and approving authority;

• summary evidence under all six domains;

• the precise learning question;

• options considered and why each was accepted or rejected;

• selected response, scope, owner, required capability and expected timescale;

• where capacity prevents the preferred response: preferred option, unmet capability, accountable escalation recipient, interim mitigation, response/review date and trigger, and any residual risk acceptance;

• direct-involvement status, contact attempts or reason involvement is unavailable, questions and preferences of patients, families and staff, required communication/accessibility support, any provisional status and the trigger for reconsideration;

• equity and accessibility considerations;

• uncertainties, dissent or minority view;

• communication commitment; and

• review date and explicit triggers for reconsideration.

5. Three Worked Synthetic Cases

Fictional examples only. Every person, organisation, service, number, technology, timeline and event below is invented. The cases are not composites and are not adapted from the author’s employers or any identifiable healthcare incident. They demonstrate decision logic only and should not be used as clinical or legal precedent.

The cases are deliberately simplified calibration examples. They are designed to make the SELECT reasoning visible, not to reproduce the full uncertainty, documentation volume or competing pressures of a real incident. Each example shows all six domains, plausible alternatives, a human-approved outcome and explicit triggers for reconsideration.

5.1. Synthetic Case A—Outcome: PSII

Fictional situation: At an invented acute provider, a patient experiences temporary harm after an infusion is delivered using a device profile that does not match a newly introduced electronic order set. Staff stop the infusion and the patient recovers. Initial checking suggests an unexpected interaction among the prescribing configuration, a device-library update, local contingency practice and training across two departments. The organisation has no existing investigation or improvement programme covering this combined configuration.

Table 5 applies all six SELECT domains to this fictional event. The decisive considerations are the important unanswered system question, the novel cross-functional mechanism and the need for expertise across a broad system boundary.

Table 5. Application of the six SELECT domains in synthetic case A.

Note. All content is wholly synthetic and does not represent any real patient, staff member, organisation or incident.

Why PSII is proportionate. The decision is driven by important new system learning and a complex cross-functional boundary—not by harm severity alone. The external device route runs in parallel and informs coordination; it does not replace the PSII.

Table 6 records the resulting human-approved decision, the alternatives considered and the circumstances that would require reconsideration. It demonstrates that SELECT produces a transparent narrative record rather than a score.

Table 6. Synthetic case A decision record and reconsideration triggers.

Note. PSII, Patient Safety Incident Investigation; MHRA, Medicines and Healthcare products Regulatory Agency.

5.2. Synthetic Case B—Outcome: Thematic Review

Fictional situation: Over a hypothetical six-month period, an invented community-and-acute pathway records eleven reports involving delayed follow-up of diagnostic results after transfers between services. Individual events differ and most cause no or low harm. An initial scan suggests recurring hand-off, ownership and electronic-worklist themes. Several one-off local discussions have occurred, but no cross-case synthesis has been undertaken.

Table 7 applies SELECT to a pattern of related fictional events. Here the correct learning unit is the cluster rather than any single incident, and the key need is to understand recurring conditions across organisational interfaces.

Table 7. Application of the six SELECT domains in synthetic case B.

Note: All content is wholly synthetic and does not represent any real patient, staff member, organisation or incident.

Why thematic review is proportionate. The learning unit is the pattern, not one incident. The selected response is more likely to reveal recurring conditions, population differences and control weaknesses while avoiding duplicated investigations.

Table 8 shows how the thematic review is distinguished from multiple separate PSIIs, a single-event investigation or an audit alone. The record also makes coordination and data-access dependencies visible.

Table 8. Synthetic case B decision record and reconsideration triggers.

Note: AAR, After Action Review; ICB, Integrated Care Board; PSII, Patient Safety Incident Investigation.

5.3. Synthetic Case C—Outcome: No Additional Individual Learning Response

Fictional situation: An invented provider records another delayed dose of a time-critical medicine during transfer between wards. The patient is assessed and experiences no lasting harm. A completed systems review two months earlier established the mechanism; a funded improvement programme is active, with named ownership, weekly process measures and evidence that reliability is improving but has not yet reached the agreed target. The new event matches the known mechanism and reveals no new population, interface or failure mode.

Table 9 applies SELECT to a fictional event for which the mechanism is already known and measured improvement is active. The framework therefore tests whether an additional individual learning response would add material knowledge rather than assuming that every event requires a new investigation.

Table 9. Application of the six SELECT domains in synthetic case C.

Note: All content is wholly synthetic and does not represent any real patient, staff member, organisation or incident.

Why “no additional response” is not “do nothing”. Care, openness, recording, engagement, monitoring, improvement ownership and reconsideration remain mandatory. The decision only avoids duplicating an analysis that is unlikely to generate new learning.

Table 10 documents the residual actions that remain required and the triggers for renewed deliberation. The example is intentionally included to show that avoiding duplicate analysis is compatible with continued engagement, monitoring and improvement accountability.

Table 10. Synthetic case C decision record and reconsideration triggers.

Note: AAR, After Action Review; PSII, Patient Safety Incident Investigation.

5.4. Cross-Case Comparison

Table 11 compares the three outcomes. The cases differ because their learning states differ: an important mechanism is unknown in case A, a pattern requires cross-case synthesis in case B, and the mechanism is already known with active improvement in case C.

Table 11. Comparison of the three wholly synthetic SELECT decisions.

Note: PSII, Patient Safety Incident Investigation.

6. How Organisations and Processes Fit Together in England

The incident-management landscape can appear confusing because different organisations answer different questions. The provider asks what happened, what can be learned and improved, and how those affected should be supported. Regulators assess compliance and quality. Independent investigators identify national system learning. Professional regulators protect the public in relation to registrants’ fitness to practise. Coroners investigate deaths and may issue Prevention of Future Deaths reports. Complaints, claims, medicines/device surveillance, safeguarding and criminal processes have separate legal or administrative purposes.

The organisations do not form one linear investigation chain. Several routes may start at the same time because they answer different questions. Table 12 presents the usual functional stages and shows the narrow point at which SELECT is proposed to operate: selection of the local learning response after urgent and mandatory screening.

Table 12. Functional stages of incident response and the proposed position of SELECT.

Note: CQC, Care Quality Commission; ICB, Integrated Care Board; LFPSE, Learn from Patient Safety Events; MHRA, Medicines and Healthcare products Regulatory Agency; MNSI, Maternity and Newborn Safety Investigations; PSIRP, Patient Safety Incident Response Plan.

Table 13 explains the principal actors in plain language and states each boundary with SELECT. Its main message is that SELECT coordinates awareness of relevant routes but does not apply their legal or regulatory tests.

Table 13. Principal organisations, processes and boundaries with PSIRF-SELECT.

Note: Abbreviations are expanded in the table and in Appendix A. Organisational roles and structures should be checked against current official guidance before implementation.

A consolidated plain-English glossary of the organisations, processes and abbreviations used in this section is provided in Appendix A (Table A1).

The Boundary Rule

Different questions, coordinated processes. PSIRF learning asks how care systems can be understood and improved. Regulation asks whether standards are met. Professional fitness-to-practise asks whether a registrant presents a current public-protection concern. Coroners investigate deaths; complaints seek resolution; claims address legal liability/compensation; MHRA monitors product safety; police investigate suspected crime. SELECT records and coordinates relevant routes but does not merge their tests, evidence standards or outcomes.

7. Safeguards and Foreseeable Failure Modes

Table 14 anticipates foreseeable misuse and implementation failure. The safeguards protect the qualitative, multidisciplinary and reviewable character of SELECT and should form part of any co-design, training and pilot protocol.

Table 14. Foreseeable failure modes and proposed safeguards.

Information Governance and Psychological Safety

The decision record should contain the minimum necessary information and use existing authorised systems. It should not reproduce sensitive clinical detail where a link to the source record is sufficient. Information sharing across organisations or with external bodies requires the appropriate legal basis, agreements and access controls. The need for openness must be balanced with confidentiality and protected disclosure arrangements.

Staff participation should be supported and psychologically safe. SELECT should not be used as an interview template for testing individual credibility or as a performance-management instrument. Where there are concerns about conduct or fitness to practise, the organisation should use the relevant fair and professional processes while maintaining the systems-learning purpose [42]-[46] [50].

8. Evaluation and Implementation Roadmap

PSIRF-SELECT can move immediately into responsible critique, co-design and simulation. It should not move directly from publication to ungoverned routine adoption or be relied upon as the sole authority for a live decision. A staged programme is needed to determine whether the gap is real in varied settings, whether the tool is usable, whether different teams reach defensible decisions and whether the record improves transparency without producing new burden or inequity.

8.1. Responsible Early Use before Validation

Unvalidated does not mean unusable for learning and development. NHS organisations, ICBs, Patient Safety Partners, educators and researchers are encouraged to examine and test the proposal in controlled ways. Early use should generate evidence and improve the framework rather than imply that its effectiveness has already been established.

Table 15 distinguishes four responsible early-use modes. The boundaries become progressively stronger as the activity moves from critique and simulation toward shadow testing and a prospective pilot.

Table 15. Responsible early-use modes before validation.

Note: ICB, Integrated Care Board; PSIRF, Patient Safety Incident Response Framework.

The practical position is therefore an invitation with safeguards: use SELECT to structure discussion, compare it with current practice and report what works or fails. Do not present it as NHS guidance, a validated instrument or a substitute for the organisation’s accountable decision-making arrangements.

Table 16 sets out the proposed evaluation pathway. Each phase is designed to answer a different question, beginning with governance and content validity before progressing to feasibility, reliability, outcomes and stewardship.

Table 16. Staged evaluation and implementation roadmap.

Note: ICB, Integrated Care Board; IG, information governance; PSP, Patient Safety Partner.

8.2. Candidate Evaluation Measures

• Feasibility: completion rate, median time, missing fields, number and role of participants, and proportion needing preliminary assessment.

• Fidelity: completion of all six domains, documentation of alternatives/uncertainty/triggers, and evidence that engagement occurred before approval.

• Decision quality: independent structured review of relevance, coherence, proportionality, systems orientation and traceability—not whether reviewers personally prefer the same method.

• Reliability: agreement on response category and, separately, agreement on material considerations and learning question; report confidence intervals and expected contextual variation.

• Equity: differences in response selection, engagement and reconsideration by service, population, communication need and protected/inequality characteristics where lawful and appropriate.

• Experience: patient/family/staff perceptions of being heard, clarity of explanation, burden and psychological safety.

• Process outcomes: decision timeliness, duplication, overdue work, cross-system coordination and proportion of decisions revisited appropriately.

• Learning/improvement outcomes: quality and novelty of learning, linkage to improvement, action strength, implementation and evidence of effectiveness.

• Unintended consequences: gaming, over-investigation, under-response, delay, excessive documentation, inequitable application or inappropriate individualisation.

8.3. Invitation to NHS Partners for Phase 2

This paper actively seeks co-design and evaluation partners rather than immediate uncritical adoption. Each organisation would control its own information, approvals and accountable decisions. Participation can begin without sharing identifiable incident data with the author: partners may review the content, run the published synthetic cases, create their own fictional scenarios or compare SELECT with their existing decision process under local governance.

Responsible invitation wording. We invite NHS providers, ICBs, Patient Safety Partners, educators and researchers to critique, co-design and test PSIRF-SELECT through simulation, shadow use or locally governed pilot work. Participation would not imply NHS endorsement. No identifiable patient, staff or incident information should leave approved governance arrangements, and SELECT should not be the sole authority for a live decision.

9. Discussion

9.1. Principal Contribution

PSIRF-SELECT translates a dispersed set of national expectations into a proposed minimum deliberation and decision record. Its contribution is not another hierarchy of harm, a mandatory route or a replacement investigation method. It is a way of asking whether the selected response is traceable to specified requirements, current knowledge, a meaningful learning question, the needs of those affected, the true system boundary and a transparent rationale.

This design responds directly to HSSIB’s call for practical steps and a robust, standard approach while respecting the flexibility at the centre of PSIRF [12]. A standard process need not produce identical outcomes: two providers may reasonably choose different methods when context, available evidence or engagement questions differ. Standardisation should apply to the quality and visibility of the reasoning, not force uniform answers.

9.2. Relationship to Existing Tools

National and local tools are assets, not competitors. SELECT could sit before the NHS learning-response toolkit, documenting why a particular method is commissioned [4]. A Trust could retain its existing flowchart and add the protected SELECT minimum record. Where an existing local form already captures the six domains and the decision trail, replacement would be unnecessary. Evaluation should therefore compare integration, supplementation and no-change options rather than assume that a new standalone form is best.

International frameworks and concise-analysis tools show that proportionate, structured approaches are feasible [51] [52]. Systems frameworks such as SEIPS and the Yorkshire Contributory Factors Framework support analysis of interacting work-system conditions [23] [27]. SELECT is different in function: it selects and documents the response before detailed analysis, although its Context domain is informed by systems thinking.

9.3. Bias Awareness and Traceability

Outcome bias research provides a concrete reason to document how harm severity was used and what evidence supports perceived culpability or learning potential [19]. The author’s earlier DEEP SEE conceptual framework similarly emphasised bias-aware, contextual analysis after an event [53]. SELECT uses a narrower lesson at an earlier decision point: require explicit alternatives, uncertainty and a system question so an emotionally salient outcome does not silently determine the method. DEEP SEE is not incorporated into SELECT and has not been used as validation evidence.

The author’s DEEP SEE-MIRROR work on structured and auditable AI reasoning may be relevant to a distant digital implementation pathway [54]. However, this manuscript proposes a human deliberation process. Automated response selection, predictive scoring or language-model recommendations should not be introduced without separate evidence, governance, human-factors testing, bias evaluation, data protection and meaningful human control.

9.4. Strengths

• The proposal is explicitly anchored to current PSIRF guidance and acknowledges existing local tools.

• A direct national gap signal from HSSIB is distinguished from indirect empirical support.

• Engagement, equity, capacity, alternatives, uncertainty and review triggers are visible rather than assumed.

• Three synthetic cases demonstrate that the framework can support different outcomes without hospital data.

• The minimum record creates a basis for empirical testing, audit and revision.

9.5. Limitations

• The targeted literature and policy review was single-author and limited to accessible sources; it cannot establish exhaustive novelty.

• The framework is conceptually derived and has not undergone patient/public co-design, content validation, reliability testing or prospective evaluation.

• The minimum functional composition, approval safeguard, provisional-engagement rule, capacity-escalation record and protected-core field classification are author-proposed design safeguards requiring co-design and testing; they are not nationally mandated governance arrangements.

• The mnemonic may oversimplify complex governance and may create documentation burden or false assurance.

• Public local documents may not reflect actual work-as-done, unpublished tools or implementation outcomes.

• Synthetic cases demonstrate internal logic only; they cannot establish feasibility, safety, fairness or impact.

• Organisational roles and national structures are changing. In particular, the planned transfer of NHS England functions to DHSC means descriptions require updating before publication or implementation [31].

• The proposal was developed outside the NHS England policy process and must not be represented as official NHS guidance or endorsement.

9.6. Implications for Policy, Practice and Research

For policy, the proposal identifies a candidate minimum record that could be compared with forthcoming national work rather than promoted prematurely. For practice, it offers a language for reviewing local decision processes and explaining choices to those affected. For research, it defines a testable intervention, mechanisms and outcomes. The most important next question is not whether the acronym is memorable, but whether the process changes who is heard, what evidence is considered, how uncertainty is handled and whether the resulting learning contributes to safer care.

10. Conclusions

PSIRF created necessary flexibility to focus incident response on learning and improvement rather than rigid harm thresholds. That flexibility increases the importance of transparent, consistent and reviewable judgement. PSIRF-SELECT is a proposed six-domain deliberation and documentation framework designed to make that judgement visible while preserving local context and human authority.

The evidence reviewed supports the existence of a practical implementation need but does not prove that SELECT is the correct solution. Existing local flowcharts and tools must be recognised; the framework’s defensible novelty lies in its proposed integrated minimum record and evaluation pathway. The next stage should therefore be co-design and staged validation—not claims of adoption, effectiveness or NHS endorsement.

Acknowledgements

During preparation of this manuscript, the author used OpenAI ChatGPT (web application; accessed August-September 2026) for evidence organisation, drafting support, language editing and document formatting. The author reviewed and edited the outputs and accepts full responsibility for the final manuscript. No generative AI-created figures or research data are included in the revised manuscript.

Ethics Approval

Ethics approval was not required because this conceptual manuscript involved no human participants, identifiable personal data, patient records or organisational incident data.

Data Availability

No participant-level or organisational datasets were generated or analysed. All documentary sources are publicly accessible and cited. The worked cases are wholly synthetic. Supplementary Table S1 provides the source-by-source evidence table and maps each source to the SELECT domain(s) or design principle(s) it informed.

Author Contributions

Adel Omar Bataweel: Conceptualisation, methodology, investigation, project administration, writing—original draft, and writing—review and editing.

Appendix A. Acronyms and Plain-English Glossary

Table A1 provides a reference glossary for the organisations, processes and technical terms used throughout the manuscript.

Table A1. Acronyms and plain-English glossary.

Appendix B. Minimum Data Set and Reporting Checklist

Table B1 converts the proposed minimum record into a reporting checklist. It is a conceptual specification for co-design and testing, not a validated operational form.

Table B1. Proposed minimum data set and reporting checklist.

Note: “Required minimum” denotes the proposed SELECT protected core; it does not mean that every field is individually mandated by NHS England. All fields require co-design and feasibility testing before routine use.

Appendix C. Proposed Protected-Core Field-to-Source Crosswalk

This appendix maps every field in the proposed SELECT minimum record to its principal basis. “N” indicates an explicit national PSIRF requirement or standard; “G” national guidance or an official role/boundary source; “E” empirical or established conceptual evidence; and “D” an author-proposed design safeguard. A D classification is not an NHS mandate. The crosswalk is intended to support audit, version control and future updating during co-design.

Table C1. Proposed SELECT protected-core field-to-source crosswalk.

Note: The numerical citations correspond to the renumbered reference list. The mapping identifies principal rather than exhaustive sources. It should be rechecked whenever PSIRF guidance or the SELECT protected core is updated.

Appendix D. Supplementary Table S1

https://www.researchgate.net/publication/415566087_PSIRF-SELECT_-Supplementary_Table_S1?channel=doi&linkId=6acc5a05df27da413339983a&showFulltext=true

Conflicts of Interest

The author developed DEEP SEE and DEEP SEE-MIRROR, which are cited in this manuscript. The author declares no financial competing interests.

References