![]() ![]() However, this was removed in 2018 since financial sanctions “ reinforced the perception of a ‘blame culture’”. There were previously funding repercussions for never events (on the basis that commissioners should withhold payment for the cost of the relevant episode of care). Despite this, no SIIR was prepared and no explanation has been offered for this failure. Subsequent records persisted in identifying the level of first surgery at C4/5 and the second surgery as “revision”. Surgery at the wrong level is a “never event”. In the letter of response, it was noted that the initial surgery was carried out at C5/6 rather than C4/5 in error and the “revision” surgery was merely surgery at the right level. It was known, by the claimant’s legal team, that after initial decompression surgery the claimant underwent “revision” surgery a few days later. For example, in a recent case where I acted, a claim was advanced against a tertiary neurosurgery centre on the basis of delay to treat timeously degenerative cervical myelopathy at the C4/5 level. In many areas of clinical negligence litigation they are rarely seen, and even when clearly appropriate are not always undertaken. The use of SIIRs in litigation depends on the relevant health provider investigating and preparing a report. Witness statements are not generally voluntarily disclosed but in appropriate cases can be requested. Since SIIRs are not prepared with litigation in mind, they are not subject to legal professional privilege and neither is material gathered nor witness statements obtained for the purpose of the SIIR. SIIRs are not prepared with litigation in mind and will not apply the Bolam test. To a certain extent, this is a valid observation. A full admission was made in the letter of response.ĭespite this, it is not uncommon for a Defendant trust to seek to row back from acknowledgements of “missed opportunities” in SIIRs. The SIIR was conclusive as to breach and implied causation. A letter of claim was drafted, again without commissioning expert evidence, in relation to the death of a patient subsequent to hysteroscopy resulting in perforation of her bowel and the development of peritonitis not immediately recognised.Causation was not expressly dealt with in the SIIR but a full admission was made in the letter of response. The allegations focused on failures of cardiotocography monitoring in light of reduced fetal movements and failure to undertake obstetric review to consider mode and timing of delivery. A letter of claim was drafted in relation to the stillbirth of twins based purely on the SIIR and without obtaining breach or causation expert evidence.For example, in two recent cases I have dealt with: In many cases, breach of duty, if not causation, can be established from the report. There is no doubt that SIIRs can be helpful in clinical negligence litigation. There is a list of never events which is periodically updated. Never events as defined by the Never Events Policy and Framework which are, in broad terms, patient safety incidents that are wholly preventable and which have the potential to cause serious patient harm or death.Unexpected or avoidable injury resulting in serious harm.The Serious Incident Framework provides an indicative list of incidents requiring investigation including: 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. In relation to the threshold for investigation, the Serious Incident Framework provides: The Serious Incident Framework, last updated in 2015, endorses the application of root cause analysis as “ a powerful mechanism for driving improvement” and notes “ the fundamental purpose of safety investigation, … is to learn from incidents, and not to apportion blame”. The Serious Incident FrameworkĬlinical negligence practitioners will be familiar with the Serious Incident Framework and, in particular, the Serious Incident Investigation Report (“SIIR”) prepared pursuant to that framework (sometimes referred to as an RCA, root cause analysis, or SUI, serious untoward incident). The transition to PSIRF from the Serious Incident Framework should be completed by autumn 2023. In response to the perceived failures to the improvement of patient safety, NHS England are introducing the Patient Safety Incident Response Framework (“PSIRF” pronounced “pea surf”) to replace the Serious Incident Framework. Despite the “never event” framework, the number of such incidents remains stubbornly high. This article produced by Justin Valentine has been published in the AvMA Lawyers Service Newsletter (November 2023) which you can download here.Ī criticism of the NHS generally is that it does not learn from mistakes. ![]()
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