A Serious Untoward Incident is an investigation process in hospitals that happens following the death or harm of someone due to failures in care, the type of thing that might attract media interest, litigation etc. We have been involved in one following the death of our baby.
The idea behind it is that time and resources are made available to properly investigate what occurred, to sift through the wreckage so to speak, and learn how not to make the same mistakes over and over again. As Richard Branson, the new vice-president of the Patients Association pressure group, puts it,
“One in ten people who go into hospital have what they call an adverse event . . In the airline industry, if we had that kind of track record, we would have been grounded years ago. And what happens in the airline industry, if there is an adverse event, that information is sent out to every airline in the world, and every airline makes certain that that adverse event doesn’t happen twice.” ref.
Our experience of the NHS equivalent has not been good. The investigation has been treated as an administrative procedure and we have had to chase it every step of the way just to keep it going. That is hardly what you’d call serious. Eight months after the event, the story (let alone the lessons) is still not properly sorted, and there seems to be no way for lessons to be disseminated anyway. The basic problem is that the medics involved do not seem to treat the process as something upon which future lives actually depend (which obviously they do!), but rather as a potential minefield of litigation and disciplinary action (e.g. see this or this for just how endemic and bad it can be), or as something that might produce even more red tape, or as something that takes them away from their important day jobs etc. Our’s has been sloppy and careless, and it’s been getting worse. If our serious untoward incident had been one of their patients, it would have died by now. Certainly, it has not been taken as seriously as actual care would be.
The thing is, that if something this important is done badly or treated without the care that it should get, more babies WILL die. That’s not being dramatic, that’s just obvious. There are probably legal principles that can be used to charge hospitals who fail to take serious untoward incident reporting seriously with negligence.
I shall try and look into this some time soon.
UPDATE: It seems there is at least some legal basis to the right to expect a reasonable investigation in Human Rights legislation, but this is not necessarily the responsibility of the hospital, but probably the Coroner.
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