My reflections on the revised Serious Incident framework

Colleagues have been encouraging me for some time to write a blog. This is my first foray into the blogging world and I hope it is of some interest and benefit for readers.

My blog is about my reflections on the revised SI framework for England effective as of the 1st April 2015. The changes in this document are, in my professional opinion, a welcome change in approach. It gives NHS Trusts the opportunity to consider more carefully those investigations that require a more in-depth review rather than being ‘forced’ to apply a ‘same size fits all’ mentality which prevailed prior to the 1st April 2015.  Essentially the new guidance enables Trusts to focus on those serious incidents that have happened as a consequence of care, treatment or process lapses, rather than those serious incidents that have occurred in spite of excellent, good or reasonable care.

I anticipate that this will be challenging for Trusts. I know from speaking to colleagues working within the NHS that  the fear of ‘getting it wrong’, deciding not to conduct a full SI investigation and being criticised for the decision is causing some degree of paralysis in moving towards a more moderated and sensible approach to incident investigation.

This is a fear that must be conquered. The only way we can optimise effective learning from the incidents that we have helped cause, is to investigate less, and to spend our investigatory effort more wisely.

To achieve this Trusts who have evolved a tightly centralist approach to governance and safety may need to reconsider their approach and revert to a model where the control for decision making is passed back to services / directorates and divisions. Those of you who have been working in governance and safety since the 1990’s will recognise this model as it is where we all started –  ‘local ownership’ with central support.

Trusts may also need to consider reviewing their frequently occurring incidents where sometimes they are ‘because of us’ and sometimes they are ‘in spite of us’. Is there scope to develop a standardised screening tool for clusters of some incident types (similar in approach to the screening tools developed for pressure damage cases) that can be used by local team leaders, or in aggregated peer review activities? ‘Cases’ that ‘pass’ the screening process may not require any further in-depth investigation. Cases that ‘fail’ the screening process may well require further investigatory activity. The screening process should provide clear perspective about ‘what’ needs further investigation.

What I am advocating is a clear, auditable and stepped approach to the investigation process that enables safe decision making, based on a case by case assessment.  Essentially a process that enables all serious incidents to benefit from what I refer to as Part A of the investigation process, which should establish – what actually happened and what should have happened, and what are the differences between the two maps. This enables clarity to be achieved regarding:

  • incidental or ‘soft learning’ lapses in performance (human and system)
  • significant or ‘lapses of magnitude’

My perspective is that the optimal learning opportunities from single incident reviews are more likely to emerge from exploring lapses of magnitude than from incidental lapses. In the interests of proportionality these are possibly best explored once there is a cluster of similar type issues.

To achieve a saner and more proportionate approach to investigating unexpected adverse outcomes of care within the NHS, it could be useful to visualise the investigatory process as a bus journey with different ‘get off’ or ‘stop’ points.

All ‘moderate – serious’ adverse outcomes need some level of investigation otherwise we have no idea whether this has happened ‘because’ of ‘us’, or in spite of us. Therefore it makes sense that all investigations start in the same place – that is a consideration of what did happen and what should have happened. It is the output of this consideration that ought to dictate further investigatory effort. This allows for a variety of ‘stop’ points along the investigation pathway.