Patient and Family Liaison

Following a serious incident or tragic loss of life involving both outpatients and inpatients, all NHS Trusts are required to complete a Serious Incident Report (SIR). 

This takes place within the NHS Serious Incident Framework which is currently being updated and revised via the Patient Safety Incident Response Framework (PSIRF).  According to the NHS, the primary purpose a Serious Incident Report is to ensure that incidents are fully investigated and that lessons are learnt which will reduce the likelihood of similar incidents occurring in the future.

Enshrined in the Health & Social Care Act (2008), the SIR process is supported by the Care Quality Commission (CQC) regulated Duty of Candour legislation which requires that all medical professionals are open and honest with patients and their families when something goes wrong, most especially when this involves loss of life.

In the event of an untimely death, the relevant Coroner will open an Inquest. SIR investigations and related processes are frequently a key component of Inquest proceedings and can be vital in establishing the full facts of a case and registering an official cause of death.  In some cases, including my own, this can result in the issuing of a Prevention of Future Death notice.  Transparent, comprehensive and empathetic engagement with families is fundamental to Inquest proceedings.

Speaking from personal experience, as a father bereaved by suicide, it is clear that whilst the objectives of the SIR and inquest processes are commendable, the actual experience of participation can frequently and unfortunately be extremely distressing. In the wake of a tragedy, families, friends, colleagues and communities are invariably traumatised by the experience. Indeed, and again speaking personally, such events can frequently result in the most profound level of distress imaginable.

Following a loss, in the midst of great pain, families are required to navigate the typically unfamiliar and overwhelming processes associated with investigations, funerals, inquests, the emergency services, legal proceedings and the media. They are usually required to do so when they are at their very lowest level of resilience and capability. The SIR process forms a key part of this landscape and, improperly conducted – as has commonly been the case in the past – SIR investigations can greatly add to and compound the grief and trauma of a family rather than alleviate it. This can then subsequently impair Inquest proceedings and other legal processes, further compounding the tortuous path many families have to walk after they have lost a loved one.

At the same time, medical professionals can also be deeply impacted by a serious incident or tragic outcome. Personal distress is often compounded by a fear or recrimination, remorse and retribution. Professionals require support and guidance post-tragedy in the same way that families and loved ones do. It is also imperative that professionals are supported by their employers in the drive towards honesty and learning.

On paper, the SIR process is designed to identify failings, offer apologies where appropriate, create lessons learnt, revise medical practice where appropriate and bring all parties together in a spirit of open, honest and constructive dialogue. Far too often however, this process is characterised by poor communication, a lack of empathy, adversarial dialogue, a lack of transparency, the spectre of legal proceedings and general mistrust often played out over many long and painful months for all concerned.

It is with this in mind that CPFT are promoting the role of Patient & Family Liaison Officer (PFLO). This role provides a crucial link between the Trust and families as they negotiate the difficult and complex SIR process and related matters, including inquests.

It would be absurd to suggest that a forensic examination of a tragedy should be a positive experience.  It could and should however, be a process founded on honesty, transparency, support, empathy, collaboration and learning, set within a desire to alleviate trauma and generate constructive outcomes. The CPFT Officer is supported by the Trust and extensive resources which are profiled in this section of the website.

Steve Mallen
Co-Founder, Zero Suicide Alliance (ZSA)
Member – National Suicide Prevention Strategy Advisory Group (NSPSAG), DHSC

The Patient and Family Liaison Officer will:

• Develop a supportive and ethical relationship with the family by building trust.
• Act as a single point of contact and sharing information between families and the Investigation Manager.
• Provide information about additional services available to families and signposting to support agencies, such as bereavement support charities.
• Explain how Coroners work if appropriate, so that families can access related services and support.
• Record any contact they have with the family.
• Share questions or concerns raised by family with the investigation team.
• Ensure equality and diversity needs are considered.
• Update families about the progress of the investigation.
• Ensure famliles continue to be supported, if needed, when the investigation closes.

Leaflets

coroner-investigations-a-short-guide.pdf [pdf] 113KB
NHS Bereavement Leaflet.pdf [pdf] 147KB
Support Group leaflet August 2021.pdf [pdf] 216KB
Life Craft - Suicide Bereavement Support Service Leaflet.pdf [pdf] 724KB
England - Help is at Hand.pdf [pdf] 3MB

Websites

INQUEST is the only charity providing expertise on state related deaths and their investigation to bereaved people, lawyers, advice and support agencies, the media and parliamentarians. https://www.inquest.org.uk/

Rethink Carer Support Cambridgeshire and Peterborough provides support for carers, friends and families who are supporting loved ones affected by mental illness https://www.rethink.org/help-in-your-area/support-groups/rethink-carer-support-cambridgeshire-and-peterborough/ Call 07783 267013 or email CambridgeRethinkGroup@rethink.org for further information.