Patient Safety ─ Investigating and Reporting Serious Clinical Incidents

At a time of increasing regulatory scrutiny and medico-legal risk, managing serious clinical incidents within primary care has never been more important. Failure to manage appropriately can have serious consequences both for service organisations and for individuals involved.

This is the first book to provide real practical and detailed guidance on how to conduct incident investigations in primary care. It explains how to recognise a serious clinical incident, how to conduct a root cause analysis investigation, and how and when duty of candour applies. As well as covering the technical aspects of serious incident recognition and report writing, the book includes a wealth of practical advice and Top Tips, including how to manage the common pitfalls in writing reports. It has practical advice as well as some new and innovative tools to help make the RCA process easier to follow. The all-important human factors in clinical incidents are explored in detail, with multiple examples and worked-through cases studies as well as in-depth sample reports and analysis.

This concise, practical guide offers a master class for anyone performing RCA and aiming to demonstrate learning and service improvement in response to serious clinical incidents. It is essential reading for any Clinical or Governance leads in primary care, including GP practices, Out of hours, urgent care centres, prison health and NHS 111 services. It also offers valuable insights to any clinician who is in training or working at the coal face who wishes to understand how serious clinical are investigated and managed.

Dr Russell Kelsey is Regional Medical Director of North and West, Health Care Division, Care UK, the largest independent provider of NHS care in the UK. His role encompasses clinical governance for provision of out of hours and NHS 111 services to a region with a patient population of over 5 million. He is also Care UK Subject Matter Expert in Serious Clinical Incident investigation and provides CPD accredited training in SI recognition and RCA for both internal Care UK staff as well as for NHS colleagues from outside the organisation Russell has received training from both NPSA and NCAS in case management and is NPSA trained as a