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Serious Untoward incident Reports (SUIs)

On occasion following a potential adverse incident at hospital the Trust or Health Board will undertake a serious untoward investigation. These are thorough internal investigations follow a serious untoward incident.

The investigation usually involves those investigating considering the medical records, Trust guidelines and interviewing the clinicians involved in the care. The author of the report will then prepare a detailed chronology of events and consider a root cause analysis of what factors played a part in allowing the incident or mistake to occur. The serious untoward incident report will usually set out recommendations, which if implemented, would reduce the risk of a similar incident occurring in the future.

The usual factors considered as part of the investigation are as follows;

  • Notable Practice;
  • Care and service delivery problems;
  • Contributory factors;
  • Root causes;
  • Lessons learned.

Serious Untoward incident Reports (SUIs)

Some Trusts take this process very seriously and realise the importance of learning from mistakes. It is often the case that whilst mistakes are identified within the serious untoward incident reports thankfully the harm which has been caused on that occasion has been minimal. Trusts will however assess not only the actual injury but also;

  • The potential severity;
  • The likelihood of recurrence at that severity;
  • The risk rating.

This allows the Trust to properly consider the need for changes in practice and training. Simply because the harm has been limited on this occasion does not mean it will be the same if the mistake were to be replicated.

The problem with Serious Untoward incident Reports

The first issue with reports of this nature are they can be very technical and difficult to follow. They are often drafted using complex medical language which can make understanding the identified failures confusing. Whilst those investigating will usually explain where they think some treatment has fallen below a recognised standard it is very often the case that it is impossible to understand what it is they believe has been the consequences of those failures (i.e. the injury). The reports will often make significant reference to a patient’s co-morbidities or other health issues when commenting upon the impact of any failures in care such as a delay in conducting surgery.

The second issue is that the reports can be defensive and drafted perhaps unintentionally with the aim of downplaying the failures and/or the consequences of these failures. The investigation is after all conducted by the hospitals themselves rather than an independent investigator.  We have on many occasions been instructed in cases in which the serious untoward investigation has concluded that the failures were very limited and / or the harm has been minimal but our independent evidence has contradicted this and we have subsequently succeeded in proving that a significant injury has been sustained as a consequence of medical negligence.

If you have received or been informed that a hospital are undertaking a serious untoward investigation we would recommend that you obtain independent legal advice from a medical negligence specialist.

Contact our Medical Negligence Lawyers

Richard Malloy is a Solicitor and Head of Medical Negligence at Gregory Abrams Davidson Solicitors. Gregory Abrams Davidson Solicitors are Solicitors who specialise in obtaining compensation for clients who have sustained injuries as a result of Medical Negligence. We deal with claims for compensation against hospitals (both NHS and Private), dentists, general practitioners, pharmacists and opticians. We have offices in Liverpool City Centre, Allerton, Garston Village and Golders Green, London. We offer a free initial case assessment and No Win No Fee Funding is available To enquire contact a member of our Medical Negligence new enquiries team on 0151 236 5000, email This email address is being protected from spambots. You need JavaScript enabled to view it. or complete our online contact form.

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