Lauren Ramsey ^1* Joanne Hughes ² Debra Hazeldine ³ Sarah Seddon ³ Mary Gould ³ Jo Wailling ⁴ Jenni Murray ³ Siobhan Mchugh ⁵ Ruth Simms-Ellis ^3,6 Daisy Halligan ³ Katherine Ludwin ⁷ Jane K O'Hara ⁸

• ¹ Yorkshire and Humber Patient Safety Research Collaboration, Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Yorkshire, United Kingdom
• ² Harmed Patients Alliance, Caimbridge, United Kingdom
• ³ Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Yorkshire, United Kingdom
• ⁴ Victoria University of Wellington, Wellington, Wellington, New Zealand
• ⁵ Leeds Beckett University, Leeds, England, United Kingdom
• ⁶ University of Leeds, Leeds, England, United Kingdom
• ⁷ Midlands Partnership NHS Foundation, Stafford, United Kingdom
• ⁸ THIS Institute, University of Cambridge, Cambridge, England, United Kingdom

Background: Healthcare organizations risk harming patients and their families twofold. First, through the physical, emotional and/or financial harm caused by safety incidents themselves, and second, through the organizational response to incidents. The former is well-researched and targeted by interventions. However, the latter, termed 'compounded harm' is rarely acknowledged.Aims: We aimed to explore the ways compounded harm is experienced by patients and their families as a result of organizational responses to safety incidents and propose how this may be reduced in practice.Methods: We used framework analysis to qualitatively explore data derived from interviews with 42 people with lived or professional experience of safety incident responses. This comprised 18 patients/relatives, 16 investigators, seven healthcare staff and one legal staff. People with lived experience also helped to shape the design, conduct and findings of this study.Findings: We identified six ways that patients and their families experienced compounded harm because of incident responses. These were feeling: (1) Powerless, (2) Inconsequential, (3) Manipulated, (4) Abandoned, (5) De-humanized, and (6) Disoriented.Discussion: It is imperative to reduce compounded harm experienced by patients and families. We propose three recommendations for policy and practice: (1) The healthcare system to recognize and address epistemic injustice and equitably support people to be equal partners throughout investigations and subsequent learning to reduce the likelihood of patients and families feeling powerless and inconsequential. (2) Honest and transparent regulatory and organizational cultures to be fostered and enacted to reduce the likelihood of patients and families feeling manipulated. (3) The healthcare system to reorient towards providing restorative responses to harm which are human centered, relational and underpinned by dignity, safety and voluntariness to reduce the likelihood of patients and families feeling abandoned, de-humanized and disoriented.