Recommendation 114

Complaints of serious incidents trigger investigation


A fundamental principle of the current complaints arrangements for handling NHS and adult social care complaints is that a case should be handled according to the needs of that individual case. Investigation should be proportionate to the needs of the case, but any concern about patient safety needs to be robustly investigated. The Department of Health strongly agrees that complaints amounting to a serious or untoward incident warrant independent local investigation and we want to see all NHS trusts using their statutory powers to offer this to patients.

NHS England’s guidance The Serious Incident Framework sets out how serious incidents should be managed. It states that ‘initial incident grading should err on the side of caution, categorising and treating an incident as a serious incident if there is any possibility that it is.’ Furthermore it states that ‘all serious incidents should be investigated using best practice methodologies such as root cause analysis.’ Any complaint alleging that a Serious Incident has occurred should therefore be investigated. The Care Quality Commission already uses a range of information about complaints to inform the timing and focus of its inspections, and through the Chief Inspectors, is currently exploring how it can give greater prominence to complaints and safety alerts in its revised surveillance and inspection model.

The definition of a Serious Incident is an incident that occurred during NHS funded healthcare (including in the community), which resulted in one or more of the following:

  • unexpected or avoidable death or severe harm of one or more patients, staff or members of the public
  • a never event – all never events are defined as serious incidents although not all never events necessarily result in severe harm or death
  • a scenario that prevents, or threatens to prevent, an organisation’s ability to continue to deliver healthcare services, including data loss, property damage or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population
  • allegations, or incidents, of physical abuse and sexual assault or abuse, and/or
  • loss of confidence in the service, adverse media coverage or public concern about healthcare or an organisation.

The current NHS England Serious Incident Framework is a working draft and will therefore be updated and clarified in relation to this recommendation.


NHS England’s guidance The Serious Incident Framework sets out how Serious Incidents should be managed. NHS England is reviewing the Serious Incident Framework, but it agrees it is important that the level of investigation required following a serious incident will vary according to the severity of the incident. In some circumstances, fully independent investigation by an external team will be appropriate.

NHS England will be publishing an update of the Serious Incident Framework in due course.