RQIA publish quality assurance report of the review into handling of serious adverse incidents

Date published: 06 July 2015

A review of the Handling of Serious Adverse Incidents (SAIs) across the five Health and Social Care Trusts has today been published by the RQIA.

The report is one of a number of actions commissioned by the previous Minister, Edwin Poots to promote good quality and governance across health and social care and to highlight the need for openness and transparency. It looks at the reporting period between 1 January 2009 and 31 December 2013, and is based on an audit of the reporting systems and processes in place at the time of the review.

The term SAI is used within a health and social care context and is defined as an event or circumstance that could have or did lead to harm, loss or damage to people, property, environment or reputation. The purpose of the SAI system is to promote learning, and to ensure as best we can that adverse incidents do not happen again.

Commenting on some of the key points in the report Health Minister Hamilton said: “RQIA has confirmed that the information submitted by Trusts provides an accurate reflection of the handling of each SAI reviewed, and that all HSC Trusts view the SAI arrangements as a core part of their overall system from learning when things have the potential to or do go wrong, and the commitment of all staff to involve people in the review of the quality of care provided.”

The review identified that in the vast majority of cases where a patient had died, the statutory requirement to inform the Coroner had been complied with, where it was appropriate to do so. In a very small number of cases, the death was reported to the Coroner sometime after the date of death.

Commenting on this the Minister said: “A key characteristic of these cases is that the information which might have suggested that referral to the Coroner was necessary was not available at the time of death. I am confident that the roll-out of the Regional Mortality and Morbidity Review System will ensure that all deaths in hospital are appropriately reported to Coroner.”

The RQIA report made a number of recommendations, some of which were already highlighted in Sir Liam Donaldson’s recent report, ‘The Right Time, The Right Place’. These recommendations, along with other recommendations relating to incident reports will be progressed by the Department in liaison with the HSCB.

Notes to editors: 

  1. The Donaldson Report, The Right Time, The Right Place’, was published by the Health Minister Jim Wells on 27 January 2015. It sets out 10 recommendations which refer to a wide range of areas across the health service in Northern Ireland.
  2. Media enquiries about this press release to DHSSPS Press Office on 028 9052 0074, or out of office hours contact to Duty Press Officer via pager number 07699 715 440 and your call will be returned.

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