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What is a Serious Incident

In broad terms, serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare

The occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm7 to patients or staff, future incidents of abuse to patients or staff, or future significant reputational damage to the organisations involved. Serious incidents therefore require investigation in order to identify the factors that contributed towards the incident occurring and the fundamental issues (or root causes) that underpinned these. Serious incidents can be isolated, single events or multiple linked or unlinked events signalling systemic failures within a commissioning or health system

There is no definitive list of events/incidents that constitute a serious incident and lists should not be created locally as this can lead to inconsistent or inappropriate management of incidents. Where lists are created there is a tendency to not appropriately investigate things that are not on the list even when they should be investigated, and equally a tendency to undertake full investigations of incidents where that may not be warranted simply because they seem to fit a description of an incident on a list

The definition below sets out circumstances in which a serious incident must be declared. Every incident must be considered on a case-by-case basis using the description below. Inevitably, there will be borderline cases that rely on the judgement of the people involved

Serious Incidents in the NHS include:

  1. Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:
    1. Unexpected or avoidable death of one or more people. This includes:
      1. suicide/self-inflicted death; and
      2. homicide by a person in receipt of mental health care within the recent past;
    2. Unexpected or avoidable injury to one or more people that has resulted in serious harm;
    3. Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent:
      1. the death of the service user; or
      2. serious harm;
    4. Actual or alleged abuse; sexual abuse, physical or psychological ill- treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self- neglect, domestic abuse, human trafficking and modern day slavery where:
      1. healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or
      2. where abuse occurred during the provision of NHS-funded care. This includes abuse that resulted in (or was identified through) a Serious Incident;
  2. A Serious Case Review (SCR), Safeguarding Adult Review (SAR), Safeguarding Adult enquiry or other externally-led investigation,where delivery of NHS funded care caused/contributed towards the incident;
  3. A Never Event – all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death. See Never Events Policy and Framework for the national definition and further information;
  4. An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
    1. Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues;
    2. Property damage;
    3. Security breach/concern;
    4. Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population;
    5. Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS);
    6. Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services); or
    7. Activation of Major Incident Plan (by provider, commissioner or relevant agency)
  5. Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an Organisation

 

Click here for a video produced by the Improvement Patient Safety Team outlining the plans for the future of patient safety investigations

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