A Serious Untoward Incident (SUI) is the term used in the NHS where loss of life or serious injury has been unexpectedly sustained during care. It kicks off an investigation into what occurred, with the emphasis on learning from mistakes, rather than on apportioning blame. The SUI process is probably your best chance for a proper investigation following a neonatal death.

What should happen is that an ‘Immediate Notification’ form is filled in by the senior staff involved in the case and sent off to the Risk Manager. Corporate types will be notified immediately in case there is media interest, and the Director of Operations decides what type of investigation is required. The options are:

• No further action.
• A Local Review, to be undertaken by the Consultant involved, plus other staff members with the appropriate experience, and who should report to the Governance Committee with their findings within two months.
• An Organisational Internal Review, consisting of at least three experienced senior professionals. The nominated chair will have demonstratable independence from the department where the incident took place. At least one of the three must not be employed by the Trust in question. They should report their findings to the Governance Committee within 16 weeks.
• An Independent External Review, organised by the Chief Executive and the Strategic Health Authority, in cases where other legal considerations may be significant (e.g. the State was involved).

Throughout the process, consideration should be given to the support of staff and family/carers. Reviews must investigate the circumstances surrounding the incident, use analytical tools such as root cause analysis and produce a report on its findings, including:

• Description of the incident.
• Chronology of events.
• Root cause analysis.
• Views of staff.
• Possible concerns for service.
• Areas of good practice.
• Action plan and recommendations.
• Grading of the incident.

On receipt, the Governance Committee must agree the content and then disseminate it for learning, having decided with the Chief Executive beforehand the level of information to be communicated and the recipients of it (see here for some idea of just how ‘closed’ this process may be). Close links will be maintained with the Complaints and Litigation Department. Consideration will also be given to other agencies that may be involved, for instance, the NHS Litigation Authority and the Coroner.

(This is a summary of the PCT SUI guidance valid until March 2009.)

Related posts:

• Serious Untoward Incident Reporting is a Matter of Life and Death.
• How more might be learned about Stillbirth and Neonatal Death.
• Incident-triggered random clinical audits.
• Professionals’ views about safety in maternity services.
• Another indication of poor NHS lesson learning.