The Challenges and Pitfalls of Serious Incident Reviews in Healthcare

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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:  

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,


  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

What makes for an effective Serious Incident Review?


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:

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


Contact Us

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