Sai

Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').

Failure to report an SAI should be a disciplinary offence.

Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.

The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.

Failure to co-operate with investigation should be a disciplinary offence.

Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.

Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …

Investigations should be subject to multi-disciplinary peer review.

Investigation teams should reconvene after an agreed period to assess both investigation and response.

Learning and trends identified in SAI investigations should inform programmes of clinical audit.

Trusts should publish the reports of all external investigations, subject to considerations of patient confidentiality.

In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.

Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after a SAI death.

Training in SAI investigation methods and procedures should be provided to those employed to investigate.

Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours.

Should findings from investigation or review imply inadequacy in current programmes of medical or nursing education then the relevant teaching authority should be informed.

Information from clinical incident investigations, complaints, performance appraisal, inquests and litigation should be specifically assessed for potential use in training and retraining.

Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.

Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths.

Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom.

The Department should expand both the remit and resources of the RQIA in order that it might (i) maintain oversight of the SAI process (ii) be strengthened in its capacity …