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Serious Adverse Incidents

As part of the implementation of the Report of the Independent Inquiry into Hyponatraemia-Related Deaths, the workstream dealing with Serious Adverse Incidents is looking for your views. In this week’s blog, Conrad Kirkwood, who chairs the workstream, explains…


The Inquiry into Hyponatraemia-Related Deaths (IHRD) was set up to investigate the deaths of five children in hospitals in Northern Ireland. It published its findings on 31 January 2018.

It found that some of the five deaths were avoidable. It also concluded that the culture of the health service at the time, the arrangements in place to ensure the quality of services and the behaviour of individuals had all contributed to those unnecessary deaths.

In total, 120 actions are required to implement the 96 recommendations.  A series of workstream have been set up and are working through those actions.  More detailed information about implementation is shown on the Department of Health website at


A Serious Adverse Incident (SAI) is when something happens with someone’s treatment or care which could have or did lead to harm.  That harm may be unexpected or unexplained and could lead to serious injury or death.  

Many of the SAI recommendations link to the need for candour and openness.  The SAI process is about learning from what went badly rather than blaming and is intended to make services safer.  There also needs to be the maximum involvement of service users and their families, so that they fully understand what is happening and can contribute to the process.  It has been rewarding for me to work closely with service users and carers who are experts by experience.  They have helped shape set of principles which set out what you should .expect as a service user or carer if you are involved in a Serious Adverse Incident. 

It is clear to me that the SAI process works better when staff and service users or carers communicate well with each other.  An SAI is often distressing for service users or carers. However staff may often find working on Serious Adverse Incidents challenging too and they will want to make sure that they put their views forward. 

As a result, I want to hear from service users and carers who have been involved in an SAI but I also want to hear from staff who have been involved. 

I hope that everyone who has been involved in an SAI will take time to read the documents which have been shared on Citizen Space with an opportunity for to provide their views:


NOTE: We are having problems with our comments system on our blog and would like to extend an apology to people who have previously experienced issues.  The PCC will soon be launching a new revamped website and so we have decided to disable commenting on the blog until our new site launches.  In the meantime, if you are still keen to share your views on what you've read, why not tweet us @PatientClient or email us at:


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