Health and Social Care Trusts' responses to SAI queries


“In the Southern Trust we are committed to providing safe, high quality care and actively promote a culture of reporting, reviewing and learning from those instances when delivery of our care doesn’t go to plan.

“Because of the complexity of some Serious Adverse Incidents, the time it takes to investigate and thoroughly review each incident can vary. We always endeavour to work closely with and support families as we work through this often sensitive process.”


“The DHSSPS requested all Health Trusts to commence a look back exercise of Serious Adverse Incident (SAIs) reports completed between January 2009 and December 2013, to examine a number of aspects of the SAI process including engagement with families. The Western Trust completed this exercise and shared its findings with DHSSPS. Following the review, the Trust identified a small number of cases between the 2009 to 2013 time frame when families/patients were not fully involved in the process. In certain cases this was due to the nature of the case or when families indicated they did not wish to be involved.

"Regional guidelines were introduced in January 2014 by the Health and Social Care Board (HSCB) and the Public Health Agency (PHA) and this provides a checklist to follow on family engagement. The Western Trust has been fully compliant with this guidance.

"The Western Trust has a robust Serious Adverse Incident process in place to maintain and further strengthen the safety of services for patients, clients, staff and the general public. The reporting of incidents and near misses is a fundamental aspect of risk management which contributes to the delivery of safe services. All SAIs are taken very seriously by the Trust and the public should feel reassured that in a survey of staff following the Donaldson Report there was a high level of understanding and commitment to the process of reporting of adverse incidents. Learning from SAIs is applied across all services to prevent any possible future re-occurrence and to minimise the impact of such incidents.”


"The Northern Trust conducts all SAI investigations in line with the Regional Procedure for the Reporting and Follow up of Serious Adverse Incidents. There are incidences where, for legitimate and valid reasons, the investigations may take longer. The Trust endeavours to ensure the outcome from all SAIs are that lessons are learnt, recommendations implemented and to work closely with families involved."


"Belfast Trust is committed to investigating adverse events in an open and transparent way, with the aim of identifying learning and improving patient care. We try to complete investigations within regionally agreed timelines where possible. However, our main focus is on ensuring thorough and complete investigations so that we can maximise the learning opportunities for the Trust and our staff and ensure that appropriate preventative measures can be taken where necessary.

"The Trust cannot comment on any individual patient; however, the figures and statements provided against regional figures appear to be accurate. We recognise that there can, at times, be a delay with completion of SAI reviews, which can be for a variety of reasons. These may include the complexity of the review or extension of its remit during an investigation, the absence of key staff or witnesses through ill health or other reasons, lack of availability of a suitable independent chair, or the need to facilitate appropriate patient or family involvement. We apologise for any upset that this may cause, but hope that there will be understanding of the need for a complete and thorough investigation of these events.

"The Trust continues to strive to complete an SAI review as quickly as possible without compromising the potential for identifying learning and will always attempt to engage with patients and or their families and or carers as appropriate. When important issues are identified during the course of an investigation, appropriate safety measures are put in place immediately as required in order to ensure patient safety, rather than waiting for the completion of the SAI investigation.”


"The Trust follows current regional guidance for the management of SAIs. Given the complex nature of these inquiries, adherence to timescales can prove challenging for a variety of reasons. Our priority is to ensure that a thorough investigation is carried out and this can inevitably lead to delays. We are also considerate of the wishes of families and their ability to engage in this process at such a difficult and emotional time. Immediate corrective actions where required will be instigated in advance of completion of the final report.

"The Trust actively embraces appropriate investigation of adverse incidents, at all levels, across services. It is worthwhile pointing out that the volume of SAIs may not be an indicator of deficiencies of care, but can be indicative of an organisation that has a culture of learning at its core."

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