Learning from incidents

Revised in 2015, the Serious Incident Framework devised by NHS England,1 describes serious incidents as those which: “Include acts or omissions in care that result in: unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm including those where the injury required treatment to prevent death or serious harm or abuse.” This article will describe the process for investigation of a serious incident by way of a case study and consider how implementing a ‘just culture’ can enhance support for staff and the investigation process.