Root cause analysis reports and serious incident reports: what are they and can I challenge one?
What constitutes a serious incident?
Unfortunately, there is no single definition as to what constitutes a ‘serious incident’ and it varies somewhat between different organisations. NHS England defines serious incidents as follows:
“Events in health care where the potential for learning is so great or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.”
This is likely to include all incidents which directly affect patient safety and may also include those which could have an indirect effect on patient safety or an organisation’s ability to deliver ongoing healthcare.
In the context of NHS treatment, a serious incident must be declared where acts/omissions occurred that has resulted in:
- a ‘never’ event: a set list of serious and preventable safety incidents that should not occur if available preventative measures have been implemented, for example like surgery being performed on the wrong limb, or foreign objects being left in a person’s body after an operation
- unexpected or avoidable death, including self-inflicted deaths
- unexpected or avoidable injury that has resulted in serious harm
- unexpected or avoidable injury that requires further treatment by a healthcare professional in order to prevent the death of the service user or serious harm
- actual or alleged abuse
- an incident that prevents or threatens to prevent an organisation’s ability to deliver an acceptable standard of healthcare services consistently
- systemic failure to provide an acceptable standard of care.
What does a serious incident report investigation involve?
Unhelpfully, there are a number of different terms used to describe incident reporting and these are often used interchangeably.
Sometimes an investigation of this type is referred to as a Root Cause Analysis Investigation Report (RCA), a Serious Untoward Incident Report (SUI) or a High Level Investigation (HLI). These may all have slightly different inclusions and formats, depending on the organisation who is undertaking the investigation, but the end result should effectively be the same; establishing the cause and contributing factors, as well as identifying lessons that can be learned as a result.
The investigation is likely to include:
• Establishing exactly what happened
• Considering the concerns of the family
• Conducting a thorough and robust investigation in order to reassure the family, and any other interest party such as a Coroner or regulatory body
• Ensuring that any points of concern and action points are addressed promptly.
How will I know if a serious incident investigation is being undertaken?
The hospital trust or organisation will usually contact the family and invite them to submit their views beforehand, so that they can be included as part of the investigation. The family should also be regularly updated as to when the report will be completed and a copy should be made available to them as soon as possible.
Unfortunately, this is not always the case. If you are not sure whether a serious incident report is underway then you should write to the care provider and ask them to clarify whether an investigation has been undertaken and, if so, ask that they provide you with a copy of the report.
Equally, if you are told that an investigation is not being performed, and you believe one should be, then you should write to the care provider promptly and ask them to conduct an investigation, setting out the reasons why you believe that they should do so. This is something that your solicitor would be able to advise you on in more detail.
Why is a serious incident report useful?
An investigation report can be useful for a number of reasons. It can provide the family with background information which they may previously not have known and give them some understanding as to how the events occurred.
It may also identify whether the care provider contributed to a patient’s death. Clearly this would be of the utmost importance to the family of the deceased, who will no doubt have questions as to how this could have happened.
That said, there are a number of things to be wary of when reviewing a serious incident report. Whilst the principles behind the need for Serious Incident reporting are very good, it is common for there to be difficulties with this being implemented in practice. Unfortunately, we regularly deal with families who have had to request an investigation review be undertaken when one ought to have been done automatically, families not being made aware of the existence of the investigation and/or being excluded from the process, and the serious incident report itself can often be inadequate, either because it was limited in its scope or where it seems as if the issues have not been explored in a robust way.
What happens after the serious incident report?
If, following receipt of the serious incident report, you have concerns about the level of care that has been provided then you should seek expert advice. It may be that the circumstances of the death warrant an inquest or that you are entitled to claim compensation for a loved ones’ death.
If you believe that important information is missing from the review then you may wish to go back to the author of the report to make them aware of your concerns. Should you remain dissatisfied with the final version of the report then we would strongly recommend you get in touch with a specialist lawyer who will be able to give you advice on challenging the report and related next steps.
Sadly, we see reports which conclude that the serious harm or death could not have been avoided when we do not believe this to be correct. If you have any doubts about the contents of a report then we would always recommend contacting a specialist solicitor who can review the document and advise you on this.
The vast majority of investigation reports are done internally, and are not performed independently, so we would urge caution when considering the conclusions that have been reached. Please get in touch if you have questions about SUI/RCA reports, or anything else in relation to serious harm or death of a loved one.