Management of investigations and serious incidents policy

The purpose of this policy is to ensure that risks associated with serious incidents are identified and managed in accordance with best practice and in line with the expectations of the NHS Resolution, the Health and Safety Executive, the Care Quality Commission, NHS England and NHS Improvement, Clinical Commissioning Groups and the public.

Publication date:
01 September 2019
Date range:
September 2019 - September 2022

3. Definitions

3.1 *STEIS

  • 3.1.1

    STEIS is an acronym for Strategic Executive Information System. This is a system on which NHS and other providers are required to report cases meeting the criteria of Serious Incident (as described below). It is recognised that this is expected to change in 2022/23 and the policy will be updated when this occurs.

3.2 Serious Incident (this is a case reported on *STEIS)

  • 3.2.1 

    The Serious Incident Framework of 2015 (NHSE) advises that, in broad terms, Serious Incidents are 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. Serious Incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.

3.3 Serious Incidents in the NHS include:

  • 3.3.1 

    Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:
  • Unexpected or avoidable death of one or more people. This includes
    • suicide/self-inflicted death; and
    • homicide by a person in receipt of mental health care within the recent past;
  • Unexpected or avoidable injury to one or more people that has resulted in serious harm;
  • Unexpected or avoidable injury to one or more people 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: sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern-day slavery where:
    • healthcare did not take appropriate action/intervention to safeguard against such abuse occurring; or
    • where abuse occurred during the provision of NHS-funded
    • This includes abuse that resulted in (or was identified through) a Serious Case Review (SCR), Safeguarding Adult Review (SAR), Safeguarding Adult Enquiry or other externally-led investigation, where delivery of NHS funded care caused/contributed towards the incident;
  • A Never Event - all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death (see appendix 1);
  • An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
    • Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues;
    • Property damage;
    • Security breach/concern;
    • Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population;
    • Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS);
    • Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/ unit closure or suspension of services); or
    • Activation of Major Incident Plan (by provider, commissioner or relevant agency). Please refer to the KMPT Major Incident Plan. All major incidents are reported as SI.
  • Major loss of confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation.

  • 3.3.2    
    The term Serious Incident must only be used for cases reported on STEIS. All other cases are incidents or potential Serious Incidents until determined whether to report on STEIS or downgrade to incident level.

  • 3.3.3    
    The list above is not exhaustive. There are times when cases are also reported on STEIS for transparency or significant learning.

3.4 Never Event

  • 3.4.1  
    Never events are defined by the Department of Health. The list of never-events is reviewed annually. Please refer to Appendix 1 for an up to date list.

3.5 Root cause analysis (RCA)

  • 3.5.1 

    RCA is a structured investigation that aims to identify the true causes of a problem and the actions necessary to eliminate it by reviewing the whole system within which a problem, error or incident has occurred, including human factors.

  • 3.5.2  
    The investigation must be conducted using a recognised systems-based investigation methodology that identifies:
    • The problems (the what?);
    • The contributory factors that led to the problems (the how?) taking into account the environmental and human factors and
    • The fundamental issues/root cause (the why?) that need to be addressed.

  • 3.5.3 
    The investigation must be undertaken by those with appropriate skills, training and capacity.