NI health: Serious adverse incidents 'likely to be repeated'

Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system.

The reviews take place after unintended incidents of harm and ensure improvements are made.

The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness.

It found the process was not "sufficiently robust".

The report into the systems and processes for learning after an SAI came after the public inquiry into the deaths of five children in hospitals in Northern Ireland.

The findings of the 14-year hyponatraemia inquiry found that four of the deaths were avoidable.

In the RQIA report published on Thursday, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm".

It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice."

It identified failures in the SAI procedure, including failures to:

• Answer patient and family questions

• Determine where safety breaches have occurred

• Achieve a systemic understanding of those safety breaches

• Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future

The report recommended a new regional SAI procedure and an "evidence-based approach" to determine which adverse events need in-depth reviews.

Other recommendations included conducting reviews in a "fair and reasonable" timeframe with with inclusion of families and patients.

Robin Swann said it was "one of our most significant reviews"

Mr Swann said changes to the system must promote "a culture of safety" for patients and families.

"Every day, many people experience safe, high quality health and social care services delivered by highly skilled and dedicated professionals across our health and social care sector," Mr Swann said.

"However, when the care or treatment delivered does not meet expected standards and harm occurs, it is important that we identify what happened, understand how and why it happened and learn from it."

He added: "My department will be guided by this important RQIA report as it co-designs a new regional procedure. This will support an improved approach to learning from reviews where harm has occurred, thus driving quality improvement and delivering safer services."