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Serious incidents (NIHR)

There are 10,000 Serious Incidents in the NHS/year, followed by Serious Incident Investigations. Incidents cause harm for patients and families. Poor investigations lead to further, compounded harms, perceptions of injustice, inability to find healing and litigation costs. A common reason claims are pursued is for explanations; to ‘force’ transparency.

NHS Resolution suggested involving patients and families in investigations might reduce litigations pursued for explanation. Others suggested greater involvement would support better learning. Patients and family’s campaigned for involvement.

The project has involved: Research; documentary analysis of Hospital policies, literature review and interviews with patients, families, investigators, and healthcare staff. Co-design with patients and families, staff who have been investigated, staff who have investigated, managers, policy makers and researchers. Testing the implementation of prototypes in 25 investigations across 5 organisations with ethnography to evaluate.

The “Rebuilding Serious Investigations kit” was one key COVID co-design adaptation, sent to co-design partners homes before the co-design. It built empathy for different co-designer perspectives and communicated complex research findings. It was a fictional, interactive story based on the research evidence. Participants re-constructed an incident narrative for different character perspectives then made choices about the investigation, generating different outcomes. They reflected on what this meant about the ways investigations were being conducted. Outputs are on a website explaining the new investigation process with guidance via downloadable documentation, online video explanations and signposts to wider resources. It has been embedded in NHS England Patient Safety Incident Response Framework (PSIRF), and Framework for Involving Patients in Patient Safety.