Serious Adverse Incidents

We recommend that:
• The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts in terms of making the best use of the new framework and training staff to understand it. Departmental regional support for this training would be helpful. This could take the form of multidisciplinary working groups where illustrative case studies could be used to demonstrate best practice and to discuss queries.
• There should be shared knowledge across Trusts and greater use of inter-Trust investigation leads and other mechanisms for sharing expertise.
• The emphasis of the new framework must be on rapid learning, patient involvement, and system-wide sharing of learning rather than blame.
• The Trust should use the platform provided by the Northern Ireland framework to refresh its approach to incident management. Areas for attention include the use of the current incident reporting system, the weekly incident meeting, and the clarification of responsibilities for completing the agreed learning and actions.
• The Trust should continue to improve Board oversight of SAIs and continue thematic reporting of incidents. This reporting should be further developed to ensure that Trust-wide programmes of improvement and transformation can be supported as needed.
• The Trust should continue to develop its approach to SAIs under the leadership of the Medical Director with input from senior managers in governance.
• The Trust should ensure all staff complete a mandatory programme of training that emphasises the primacy of patient safety, as well as learning from error in a way that can be understood and maintained by all staff. While clinical staff have a clear professional duty to report risks to safety, other staff need to understand they too have such a duty.