Skip to main content
Serious Incident Reports play a key role in investigating patient safety events and potential clinical negligence claims. Our specialist clinical negligence solicitors request disclosure at an early stage to help clients understand what has happened in relation to their medical treatment.
When NHS have near misses with catastrophic outcomes they will undertake an internal review and then produce a Serious Incident Report to set out what happened, how they have investigated the incident, their findings and what they intend to do moving forwards.
The report is often helpful in identifying where the breach of duty might be and also to let us know who has looked at the case in terms of investigation and comment. We can then ask for disclosure of those documents and this can help us form an initial view on the case.
At Lester Aldridge, our Clinical negligence solicitors routinely request and consider carefully, with independent experts, Serious Incident Reports when investigating potential claims and to help clients find answers at an extremely difficult time.
The Duty of Candour
The duty of candour is a legal requirement of medical professionals to inform the patient/family or next of kin about “harm related incidents”.
What is a Serious Incident Report?
A Serious Incident Report should be produced by an NHS Trust following a serious patient safety incident or near miss, particularly where the outcome has been catastrophic or unexpected.
Under the Patient Safety Incident Response Framework (PSIRF), NHS organisations are required to:
- Undertake an internal investigation
- Analyse what went wrong and why
- Identify learning points and failures in care
- Set out what actions will be taken to reduce the risk of future harm
The resulting report should explain what happened, how the incident was reviewed, the Trust’s findings, and what they intend to do moving forward.
How Serious Incident Reports help Clinical Negligence claims
Serious Incident Reports are often a key piece of evidence in clinical negligence investigations. While they are not produced specifically for legal claims, they can be extremely helpful in identifying:
- Potential breaches of duty
- Failures in systems, policies, staffing or communication
- Delays in diagnosis, treatment or escalation of care
- Whether national guidance and best practice were followed
- Which clinicians or departments were involved in the incident
Importantly, these reports often reveal who has already investigated the case and what documentation exists. This allows our experienced clinical negligence solicitors to request full disclosure of relevant records at an early stage and to assess the strength of a potential claim.
What if the report admits mistakes?
Some Serious Incident Reports clearly acknowledge failures in care. Others may be less explicit or focus heavily on systemic learning rather than individual accountability.
Even where breach of duty and causation are not openly admitted, the findings of the report can still be highly valuable in establishing:
- What happened
- What should be done to prevent recurrance
- Whether care fell below an acceptable standard
- Whether the outcome could have been avoided with appropriate treatment
The Patient Safety Incident Response Framework (PSIRF)
The PSIRF is the NHS framework that governs how patient safety incidents are investigated in England. It focuses on learning, improvement and preventing future harm, replacing the previous Serious Incident Framework. Understanding how PSIRF works — and its limitations — is an important part of assessing a medical negligence claim.
How we can help
At Lester Aldridge, we understand how overwhelming it can be to receive a Serious Incident Report, particularly when you are dealing with injury, bereavement or long‑term care needs.
Our clinical negligence solicitors can:
- Review the Serious Incident Report in detail
- Identify potential breaches or failures in care
- Obtain further disclosure of investigation documents
- Guide you through the legal process with sensitivity and clarity
- Advise whether you have a viable compensation claim
No amount of compensation can undo what has happened, but a successful claim can provide vital financial support, access to care, rehabilitation and peace of mind for the future.
If you have received a Serious Incident Report, or believe one should have been carried out, our team is here to help.
Email us at online.enquiries@la-law.com or call us on 01202 786260.
Frequently Asked Questions
The Patient Safety Incident Response Framework (PSIRF) is part of the NHS Patient Safety Strategy (2019). It guides healthcare organisations in investigating serious incidents without fear of unfair sanctions, while supporting patients, families, and staff. Its ultimate aim is to improve services by focusing on patient safety.
It replaced the 2015 Serious Incident Framework, which proved difficult to deliver. PSIRF was developed to strengthen the skills, systems, and behaviours needed to investigate serious incidents, including cases involving gross negligence manslaughter.
It is a common-law offence requiring proof that:
- A duty of care existed.
- That duty was breached.
- The breach caused or contributed to death.
- The breach amounted to gross negligence.
There is no separate offence of “medical manslaughter”; this term simply refers to gross negligence manslaughter in healthcare.
- Shift from individual blame to recognising systemic failings.
- Use data more effectively, including learning from what works well.
- Provide appropriate patient safety training.
- Focus efforts where they will have the greatest impact.
It was tested with early adopter NHS Trusts and Care UK in 2022 before wider rollout. The framework is intended to guide investigations for at least 5–10 years.
When breaches of duty cause harm—whether through misdiagnosis, treatment errors, or surgical mistakes—patients may claim compensation. PSIRF ensures investigations are fair, transparent, and system-focused, helping families understand what happened and how errors can be prevented.
Serious Incident Reports can arise in a wide range of medical settings, including:
- Birth injuries to mother or baby
- Unexpected patient deaths or stillbirths
- Neonatal deaths
- Surgical errors
- Medication errors
- Diagnostic delays or failures
- Failures in monitoring or escalation of care
- Severe harm following treatment or surgery
In some cases, the incident may be described as a “near miss with catastrophic potential”, even where the worst possible outcome was narrowly avoided.
