The Challenges and Pitfalls of Serious Incident Reviews in Healthcare

Introduction

When significant events occur in healthcare, we are required to utilise a comprehensive incident management approach to really understand what happened. Guidance documents such as the HSE Incident Management Framework 2020 and the HIQA and MHC National Standards for the Conduct of Review of Patient Safety Incidents (2017) illustrate that a robust incident management model is required to conduct an effective serious incident review. With this comes much more responsibilities and defined processes for the way that we approach incidents, should a serious incident occur.

In this blog we outline some of the key challenges that services can face when implementing a framework for the management of serious incidents and we offer guidance on how to support an effective serious incident review.

HCI Research Paper Findings

Unfortunately, within the health and social care sector, serious incidents do arise. HCI recently completed an examination of serious incident reviews in Ireland and the UK in order to identify a comparison of where the key issues arose. In our research paper “The Healthcare System: Will We Ever Learn?”, one of the key areas with reoccurring issues, was with the services’ incident management model, in particular investigation of serious incidents.

For example, in the Greater Manchester Mental Health NHS Trust: Governance and Assurance Review, it was found that incident and serious incident reporting and management failed to provide a picture of life as a service user on the wards or as a member of staff working in the Trust. It also found the Board was not clear what was happening “on the shop floor” or the quality of the assurances that were being reported to the Board.

In the Portlaoise Perinatal Investigation Report (HIQA, 2015) incident management was found to have been largely reactive and was focused only on recording incidents that occurred rather than implementing a response. Management did not collate, analyse, trend or use incident related information proactively to address risks, investigate incidents or share any learning as a result. Senior managers detailed they did not have staff with the experience and expertise required to oversee the process of investigation of serious incidents.

More recently, in relation to the Ockenden Review (2022) which was an investigation of the Maternity Services at Shrewsbury and Telford Hospital Trust, the internal incident reviews completed were often cursory, not multidisciplinary and did not identify the underlying systemic failings, and in some cases, significant cases of concern were not investigated at all. The maternity governance team inappropriately downgraded serious incidents to a local investigation methodology in order to avoid external scrutiny, so that the true scale of serious incidents at the Trust went unknown. Lessons were not learned, mistakes in care were repeated, and the safety of mothers and babies was unnecessarily compromised as a result.

What is an incident review?

An Incident Review, as defined in the HSE Incident Management Framework 2020, involves a structured analysis and is conducted using best practice methods, to determine:  

• what happened,
• how it happened,
• why it happened, and
• whether there are learning points for the service, wider organisation, or nationally.

An incident review is required where the incident is rated as a Category 1 incident, i.e. clinical or non-clinical incident rated as Major or Extreme as per the HSE’s Risk Impact Table.

Category 1 incidents reviews require a systems analysis. Systems analysis is a systematic review of an incident which involves:

1. a collection of data from the literature and records
2. individual interviews with those involved in the incident
3. analysis of this data to establish the chronology of events that led up to the incident,

to

1. identifying findings that the reviewers considered had an effect on the eventual harm,
2. the contributory factors,
3. and recommended control actions to address the contributory factors to prevent future harm arising as far as is reasonably practicable.

The Challenges of Serious Incident Reviews

• Focusing on Systems Analysis: One of the main challenges with incident reviews is ensuring a focus on a systems analysis. It is crucial that the focus of the review be on the SYSTEMS in place that are meant to support the provision of services and considering the weaknesses within those systems that allowed failures to arise. Putting blame on individuals will reduce the chances of an effective, serious and thoughtful investigation.
• Services not recognising (or accepting) when an Incident Review is required: Reviews not being recognised as a Category 1 incident and then therefore not being instigated in a timely manner which can impact on the quality of the review completed.
• Insufficient (or no) governance model in place to support an Incident Review Process: No defined roles and responsibilities for Senior Accountable Officers (SAO’s), Investigators, Liaison Officers, no Terms of Reference or Agenda for SIR Team and a general lack of clarity on the step-by-step process to be followed.
• Individuals involved in the Incident Review not sufficiently independent of the incident: When conducting a Serious Incident Review, it is imperative to have individuals with an objective mindset and the ability to step back and analyse a situation.
• Lack of training: Individuals completing the Incident Review are not trained or have no practical experience in how to manage the process.
• Lack of clarity regarding the scope of the Incident under review: There can often be lack of clarity as to what the specific focus of the review is. No timeline agreed under the scope of the review and no clarity on the individuals that need to be involved in the review, both staff and others.
• Lack of appreciation of the time required to complete an incident review: Completing interviews (including note taking and incorporating factual corrections), keeping the chronology live and completing detailed reports is demanding and time consuming. Information is continually being added and so review notes and records need to be organised and accessible.
• No access to external experts where required by the incident review.
• Lack of engagement with the affected persons: This can be a result of having no communication plan or associated communication documents such as letters, consent forms, open disclosure agreements, etc from the outset. Having no designated liaison to support initial, ongoing and close out communications can also affect engagement with the key individuals involved.
• Inability to manage interviews: If there has been insufficient preparation for the interview, for example, if you don’t know what questions you want answered or if questions are not individualised for the interviewee. An inability to facilitate in a short period of time and ensure the required questions are asked and answers provided. Also, an inability to provide support to people in an environment with a potential for a lot of emotion. A strong facilitator is needed to ensure that the correct tone is utilised, to have empathy with the interviewees but to also make sure that all the questions are answered.
• Inability to identify contributory factors that played a part in the origin of the incident.
• Ineffective involvement by the Serious Incident Management Team: The team don’t meet often enough to review the information as it arises from the review or late additions to the team, who in turn can raise queries in the review approach which can push back the cycle.
• The wrong approach to findings: In some cases, when findings are identified, there can be a reluctance to be open and honest about the findings, and to lean towards it is just one person’s fault, not an organisational issue. There can be a lack of focus on the failings within the system that allowed the issue to arise.
• Weak close out reports: Technical report writing can be difficult for incident reviews because there are so many audiences for the reports. In many cases the reports do not achieve the aim of the report, i.e. What happened, why it happened, the recommendations to reduce the risk of occurrence and address the concerns/questions raised by the affected parties. The report may not be accessible to all the audiences involved. It is important that the tone of the report is appropriate and accessible to all the audiences receiving the document such as SIR team, service users, family and staff. There may also be no real clarity on the findings, contributing factors or the recommendations made to address these.
• Ineffective actions taken in response to final report: Following a serious incident report there is no real actions taken or driving of continuous improvement to ensure actions are implemented and are effective. Services need to ask – What controls (systems and processes) do we have in place to reduce the risk of a similar incident occurring here and how assured are we that these are effective?
• No shared learnings arising from the review report: The same issues are reoccurring because there have been incorrect recommendations or ineffective implementation of recommendations and similar issues occur within the service over time.

What makes for an effective Serious Incident Review?

• Timely: Both for initial reporting of incidents and decisions taken for review must be taken in a timely manner. The HSE Incident Management Framework 2020 details timeframes for various incident categories that services must be considerate off.
• Recognition of its importance: Management of Serious Incidents require a robust, comprehensive Governance Model in place to support Incident Reviews. There must be appropriate resources in place to support its implementation such as independent investigators, SIR Team and liaison officers. It is also important to ensure you have effective information governance structures in place for management of information relating to incidents under review.
• Clarity of Scope: Ensure the Terms of Reference for the Incident is completed as early as possible for the review. Have clarity of timeline under investigation and the timeline to complete investigation. It is also important not to just focus on what happened after an incident, the timeline of the incident may start well before then.
• Preparation: Preparation is key. Draft Project Plan (with timelines) from the outset, this is particularly important when you are engaging a number of other people. A Communication Plan will be central to the effectiveness of the review to ensure that all parties involved understand when and how they will be engaged in the process, and to ensure a supportive environment is provided. Have interview question templates prepared before you go into an interview process so that you are focused on the information you want to get from the interviews.
• Communication, Collaboration & Involvement: Communications with service users/family and staff by designated Liaison officers for staff and service users/family must be in an accessible format. Give appropriate notice for interviews, have constructive questions, use an appropriate tone, empathetic engagement and facilitation. Ensure there are opportunities to provide feedback, both in factual accuracy and review of relevant sections of draft reports. It is also important to provide the appropriate supports for affected parties.
• Tenacious investigation: Thorough review of all documentation that is relevant to the case and identify the actual findings and contributory factors.
• Clarification on findings at an early stage: Ongoing communications between the Investigators and the SAO & SIR team. Discussions within the governance model to ensure all parties are aware of the findings as they are arising and open communication on what are the actual findings before drafting the report and communicating to the affected parties.
• Accessible Review Report: Easy to read, factual report that provides clarity on the process implemented and the findings arising from the investigation
• Real Recommendations: Recommendations reflective of best practice that will have an impact on the quality of service provided and not just stop gaps.
• Responsive Action Plan: Implementation of the recommendations and additional controls incorporated to drive continuous improvement.
• Shared Learning: Debriefing of staff to communicate findings and additional controls. Monitoring of lessons learned to ensure the identified issues are addressed and actions implemented.
• Review the Incident Process as part of the Review: When was the issue identified? Was it appropriately reported in a timely manner? Did the escalation process work? It is important that the early stages of the incident reporting model is feeding in to the incident review processes so that they are working cohesively together.

Conclusion

Serious Incidents Reviews may be required depending on the severity and impact of an incident. When they are needed, serious incident reviews require a comprehensive, independent review to understanding the failings of the service and detailed root cause analysis to ensure the source is addressed and learnings identified going forward.

HCI has significant experience in conducting several types of incident/complaint reviews for health and social care services, including:

• After Action Review
• Look Back Review
• Serious Incident Review
• Service User/Patient Complaint Investigation
• Aggregate Review

We conduct our reviews in line with the HSE Incident Management Framework (2020) and the HIQA National Standards for the Conduct of Reviews of Patient Safety Incidents (2017). We offer a structured review process which is developed and implemented with a service user / patient focus, working to identify the system issues that may exist and identify the actions required to drive a culture of safety within the organisation.

For more information contact HCI at 01 629 2559 or info@hci.care.

References

• HSE, 2020.  Incident Management Framework 2020. Available at: https://www.hse.ie/eng/about/who/nqpsd/qps-incident-management/incident-management/hse-2020-incident-management-framework-guidance.pdf
• HIQA, 2015. Report of the investigation into the safety, quality and standards of services provided by the Health Service Executive to patients in the Midland Regional Hospital, Portlaoise. Available at: https://www.hiqa.ie/sites/default/files/2017-01/Portlaoise-Investigation-Report.pdf
• HIQA and MHC, 2017. National Standards for the Conduct of Reviews of Patient Safety Incidents. Available at:  
• https://www.hiqa.ie/sites/default/files/2017-10/National-Standards-Patient-Safety-Incidents.pdf
• Ockenden, 2022. Findings, Conclusions and Essential Actions from the Independent Review of Maternity Services at The Shrewsbury and Telford Hospital NHS Trust. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1064302/Final-Ockenden-Report-web-accessible.pdf
• Kirkup, B., 2018. Report of the Liverpool Community Health Independent Review. V2. [Online]. Available at: https://www.england.nhs.uk/wp-content/uploads/2019/09/LiverpoolCommunityHealth_IndependentReviewReport_V2.pdf