York and Scarborough Teaching Hospitals NHS Foundation Trust

“The Trust moved to the new Patient Safety Incident Response Framework (PSIRF) in December 2023. Since that time revised systems and processes have been put in place to record, monitor, review and learn from incidents across the Trust. It is acknowledged that this incident should have had, under the old policy, a 72-hour report, and this was not undertaken. This has been reviewed within the Surgery Care Group and the new policy requiring either hot debrief or other form of incident response is now”