Self-help guide

Serious incident reports

Useful information about serious incident reports (SIRs). Please note that SIRs are being phased out and hospital trusts are adopting the Patient Safety Incident Response Framework (PSIRF) instead.

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Serious incidents

There is no definitive list of events/incidents that constitute “serious incidents”.

Serious incidents are defined by NHS England as “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.”

NHS England also makes it clear that “Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.”

In what circumstances must a serious incident be declared?

Where NHS treatment is concerned, a serious incident must be declared where acts and/or omissions have occurred as part of NHS-funded healthcare (including in the community) that has resulted in in any of the following:

• Unexpected or avoidable death of one or more people. This includes suicide or self-inflicted death, as well as homicide by a person in receipt of mental healthcare in the recent past.
• Unexpected or avoidable injury to one or more people that has resulted in serious harm.
• Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent the death of the service user or serious harm.
• Actual or alleged abuse. There are a number of situations where this applies, but in the context of clinical negligence the most relevant ones might be considered to be sexual abuse, physical or psychological ill-treatment, acts or omissions which constitute neglect, and self-neglect. It will also apply where healthcare did not take appropriate action or intervention to safeguard against such abuse occurring, or where the abuse occurred during the provision of NHS-funded care.
• A ‘never event‘. All never events are defined as serious incidents, although not all never events necessarily result in serious harm or death.
• An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services. This includes incidents in population-wide activities like screening or inappropriate enforcement/care under the Mental Health Act 1983 and Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS).
• Systematic failure to provide an acceptable standard of safe care. This may include incidents, or a series of incidents, which necessitate ward or unit closure or suspension of services.

How can I tell whether an incident is a serious incident?

This can be difficult to identify; outcome alone will not determine whether an incident is serious or not. Sometimes upsetting things happen such as death, but this does not on its own trigger a serious incident report.

If the situation is unclear, healthcare providers must discuss the circumstances with the commissioners to agree the appropriate response. It is important that discussions are open and honest. If there is doubt, an investigation should take place in order to determine whether the incident was serious.

Serious incidents may be identified in a number of ways, including allegations made by a patient or third party, or through the complaints process.

SIR investigations

How thorough is the SIR investigation?

There are three levels of investigation which may be carried out:

1. Concise investigations: These investigations are suited to complex incidents engaged at local level by a small group of individuals.
2. Comprehensive investigations: These are suited to complex issues which should be managed by a multidisciplinary team (MDT) involving experts or specialist investigators.
3. Independent investigations: These are normally reserved for situations where the integrity of the internal investigation is likely to be challenged or it will be difficult for the organisation to be objective.

Should the healthcare provider tell me they are carrying out a SIR?

The short answer to this is yes. One of the key principles underpinning an SIR is that the needs of those affected should be of primary concern.

The duty of candour and NHS principles of being open and honest envisage families or patients being involved in the process. For further information, please see our guide on the duty of candour.

When should a serious incident be reported?

Serious incidents must be reported without delay, and in any event no longer than two working days after the incident is identified. NHS trusts should have effective systems and processes in place to report, investigate, and respond to serious incidents in line with national policy and best practice.

What must the report take into account?

What’s important is that an investigation is undertaken. The investigation should ask three key questions:

1. What were the problems?
2. How did the incident happen? This will involve looking at the factors that contributed to the problem/s.
3. Why did the incident occur? This is the fundamental question.

I don’t know if an SIR has been called

It is not unusual for patients and families not to know whether an SIR has been called and prepared. If you are not sure, the best advice is to write to the care provider and ask them to clarify whether a SIR has been called, and if so to provide you with a copy of the report.

If you know that a SIR has not been called, but believe the triggers for such an investigation have been satisfied, you should write to the care provider and ask them to call an SIR, setting out the reasons why you believe they should do.

Benefits and disadvantages of a SIR

What are the problems with SIRs?

In Avma’s experience, the principles behind serious incident reporting are very good. However, we often find that in practice, problems occur. Some of the most common problems include:

• SIRs not being called when they ought to be,
• the correct level of investigation not being employed,
• the family not being made aware of, or involved in, the investigation,
• the family not being given a copy of the final report, and
• the reports not being robust enough, failing to be either sufficiently objective or comprehensive enough in scope.

Why is an SIR useful?

SIRs can be useful to identify whether something has gone wrong with care provided. It may also help to identify whether the care provided contributed to a patient’s death. If an inquest has been called, you may wish to ask the care provider to confirm whether an SIR has been prepared.

Alternatively, if you want to consider taking legal action, or just want answers to any questions you may have, the SIR may be a useful source of information.

Further information

If you would like more information on SIRs, you may find the NHS England national serious incident framework page useful. This page also contains a list of frequently asked questions about SIRs.

If you need advice on being represented at an inquest or bringing a legal claim, please refer to the relevant pages on our website:

If you wish to have your case considered by our casework department, please submit a case along with any relevant documents:

Alternatively, if you are unable to find what you are looking for on our website, you may wish to contact Avma’s helpline: