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Information for patients and their relatives

Investigation of Serious Untoward Incidents and potential Serious

Untoward Incidents
This leaflet gives you information about Serious Untoward Incidents (SUIs). It
explains what an SUI is and what happens if one occurs. It also tells you about the
process for declaring, investigating and reporting serious incidents.

How do we define an incident as a SUI?

There is no single definition of a SUI but in general terms it is something out of the
ordinary or unexpected or likely to attract concern. This may be because:
it involves a large number of patients
there is a question of poor clinical or management judgment
a service has failed
a patient has died under unusual circumstances
there is a perception that any of these has occurred.

An SUI may involve:

Trust patients, relatives and visitors.
staff or students undertaking clinical or work experience and or their tutors.
contractors or others.

Examples of SUIs include:

a serious complaint or allegation about a member of staff, or suspicion of
serious error(s) or repeated serious concern about poor clinical or
management judgment, which would cause public concern
the failure of clinical or non-clinical procedures or the use of these procedures
that is so serious as to endanger the life of a patient, member of the public or
member of staff, or to pose a serious security risk
death (including suicide), or any serious injury or life-threatening situation
a hazard to public health
serious disruption to services, for example, by a power failure
significant damage to NHS assets such as due to a fire
significant damage to the reputation of the organisation or a staff member
a significant claim for damages or legal proceedings
the suspension of a member of staff or a criminal investigation
adverse (poor) media coverage or potential regional or national interest
injury or an incident that must be reported to the Health and Safety Executive.

What happens when a SUI or potential SUI occurs?

All NHS Trusts have a policy and procedure in place to deal with any serious
untoward incidents (SUI). This is to ensure that incidents can be investigated and
lessons learned from them.

SUI Policy Patient Information Sheet July 2007

How does the SUI process work?
The incident is considered and if we think it is an SUI, or potential SUI, we will
declare this to the Strategic Health Authority and other relevant organisations. The
procedure then involves a detailed investigation, including:
reviewing documentation
taking statements
undertaking an analysis to find the cause of the incident.

A senior person is appointed to lead the investigation and to chair the SUI panel. A
person is also appointed to keep in touch with the person(s) involved in or affected by
the incident during the investigation. We try to complete our investigations and report
as quickly as possible but sometimes this can take up to three months.

What happens next?

When the SUI panel have completed their investigation, report and action plan a
copy is given to the person(s) involved in or affected by the incident. The report is
also discussed by the Trusts Governance Committee and a copy is sent to the Trust
Board. The action plan is then put into practice and audited after a year to ensure it
has been completed and the changes are still in place.

Further Information
If you would like further information on our SUI procedures please let us know by
contacting the person who gave you this leaflet or our Corporate Risk & Safety
Manager, on 020 8725 2166.

SUI Policy Patient Information Sheet July 2007