Report adverse incidents and claims

When things seem to have gone wrong or you are in need of advice or assistance, it is helpful for us to know the circumstances sooner rather than later. Talking about a difficulty can help clarify issues and alleviate anxiety and there might be some pre-emptive action we can recommend or take on your behalf.

If you are involved in an adverse incident, set down the details in writing. It can take many years for an adverse incident to give rise to a complaint or claim against you, so it makes sense to record the salient facts in the form of an incident report while they are fresh in your mind. Moreover, you may have retired, gone to live abroad, died or become incapacitated by the time legal action is taken. The patient’s medical records may not be available by then.

A report made contemporaneously will be invaluable.

Your report should

• be factual and prepared as soon as possible after the event
• be written as a plain narrative statement in the first person (eg, “I examined the patient”)
• contain the facts, avoiding comment, opinion or speculation
• be comprehensive, setting out all details of the history, examination and full management.

Keep a copy of the report in a secure personal file – not with the patient’s clinical notes.

If the incident relates to a minor, make sure that the case notes are retained until the patient is at least 25 years old. If necessary, ask the medical-records officer to mark them as not to be destroyed until a certain date.