Innovation in Learning: Collaboration Between PSIRF and Coroners
The Patient Safety Incident Response Framework changed the way trusts investigate and learn from incidents. But it created a policy conflict with the coroner’s process that NHS England left each trust to resolve locally. In this session from the Connected Health & Care Summit 2026, Stef Cormack, Head of Patient Safety at Sandwell and West Birmingham NHS Trust, shares how she and her legal colleague Conor Lees co-produced a structured inquest form with their local coroners, bridging the gap between PSIRF’s systems-focused approach and the coroner’s need for facts, causation and the balance of probability.
Watch how Sandwell and West Birmingham NHS Trust co-produced a PSIRF-aligned inquest form with their local coroners, reducing PFDs, supporting staff through inquests and delivering a standardised approach across two coronial jurisdictions.
What the session covers and what the form has achieved
This session walks through the practical reality of resolving the tension between PSIRF and the coroner’s process, including how the inquest form was designed, what it contains, and how it is used. The key outcomes were:
- A single standardised inquest form agreed with coroners across both Birmingham and Black Country jurisdictions
- Since implementation in 2024, the trust has received fewer Prevention of Future Deaths reports
- The form is used when there is no full Patient Safety Incident Investigation (PSII), bringing together learning responses, timelines, impact and actions in a format coroners can work with
- Coroners prefer the shorter inquest form over full PSII reports, which they find too lengthy
- The senior London coroner described the approach as complimentary when it was presented at a legal conference
- Staff are supported through the process with preparation sessions, anticipated questions and attendance at court alongside the legal team
