Recommendation AFA-5: Serious Adverse Incidents
From Urology Services Inquiry Report, published 24 June 2026.
Recommendation
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.
In brief (written by this site)
The Inquiry asked the Department of Health to implement the serious adverse incident framework. In July 2026, Mike Nesbitt, Minister of Health, stated that work to redesign the procedure was continuing and a new Strategic Patient Safety Incident (PSI) Framework was in final review stages (Mike Nesbitt, Jul 2026). The Minister noted that officials expected to publish the framework and begin a managed transition towards implementation in the autumn subject to his approval, though regional training support and inter-Trust knowledge sharing were not mentioned (Mike Nesbitt, Jul 2026). In June 2026, he had announced that the department would undertake an urgent and detailed review of the recommendations (Mike Nesbitt response, Jun 2026).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 5 Oct 2026. The record below is the sources' own words.
Government response
will undertake a detailed and urgent review of the findings and recommendations
Delivery
Department of Health NI says in progress (16 July 2026)
Work on the redesign of the Serious Adverse Incident Procedure is continuing. The development of a new Strategic Patient Safety Incident (PSI) Framework, alongside a comprehensive suite of supporting guidance, is well advanced and currently in the final stages of review. This is a complex and significant programme of work, bringing together multiple components to establish a coherent, system-wide approach to how Patient Safety Incidents are identified, reviewed and learned from across the Health and Social Care system in Northern Ireland. Officials are in the final stages of completing the new PSI Framework, including reflecting on the recently published Muckamore Abbey Hospital and Urology Services Inquiry Reports and, subject to my consideration and approval, expect to be in a position to publish the PSI Framework and commence a managed transition towards implementation in the Autumn.
From: AQW 49651/22-27 (Northern Ireland Assembly written question: redesign of the Serious Adverse Incident procedure), Mike Nesbitt, Minister of Health (Northern Ireland)
Site note: The answer is about the redesign of the Serious Adverse Incident procedure, the new framework this recommendation asks the Department to implement, and says the new framework reflects the Urology Services Inquiry report. It does not give the recommendation a number.
Responsible bodies
Themes and tags
Who has spoken
- Department of Health NI
Response, delivery statement