In March 2015 NHS England published a revised Serious Incident Framework, ‘Supporting Learning to Prevent Recurrence’. This framework outlines to CCG staff and provider organisations what their responsibilities are for reporting and managing SIs.
What are Serious Incidents (SIs)?
Serious Incidents are events in health care where the potential for learning is so great, or the consequences for patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to ensure a comprehensive response. SIs can extend beyond incidents which affect patients directly; including incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.
Robust investigation of SIs that occur within health and social care organisations is a proven method of improving health care through learning.
Learning following an incident is essential to improve services, and to prevent similar incidents from occurring again. Early learning to stop reoccurrence is paramount. Whether this learning is undertaken by a GP Surgery, social care or the voluntary sector, we expect the same comprehensive response as we would a large NHS Trust.
From April 2017 the way GPs will be reporting SIs has changed, as the CCG has taken on delegated commissioning. We will ask the GP to complete an incident reporting form and we will liaise with the practice about the process. Further information can be found in the CCG’s Serious Incident Policy .
The CCG aims to facilitate learning by promoting a fair, open, and just culture and promotes the belief that ‘incidents cannot simply be linked to the actions of the individual healthcare staff involved but rather the system in which the individuals were working. Looking at what was wrong in the system helps organisations to learn lessons that can prevent the incident recurring'.
Part of our process is holding learning events. These present opportunities for providers to discuss common themes and trends and to learn from each other. The CCG’s role is to ensure actions from reported incidents are put into practice. If required we will change commissioning decisions to effect any necessary changes.
Alongside the NHS England Serious Incident Framework sits the Never Events Policy and Framework (The List), which is published annually. This includes guidance on entirely preventable SIs. These safety recommendations are applicable nationally and should be implemented by all healthcare providers.
Queries or concerns
If you have queries regarding the health care provided to you or a loved one, you should first raise any concerns with the service in question. You may also get help and advice from the Patient Advice and Liaison Service (PALS) at your local hospital.
The CCG, as commissioner of health services in this area, also has a Patient Experience Team who are happy to help if you are unable to contact the relevant Trust or health service’s PALS team.
Confidentiality - All SI forms, reports and correspondence should be sent from an NHS net account to CAPCCG.SUIs@nhs.net