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ADVERSE INCIDENT REPORT

An adverse incident is an event or circumstance that might give rise to a claim, complaint or allegation against you. With claims-made protection, you are required to report an adverse incident to Medical Protection as soon as reasonably practicable after it occurs (or when you become aware that it has occurred).
In order to make an adverse incident report, please complete all the requested details below.

Your details

Details of adverse incident

(please write each name on a separate line)
If yes, please provide details and copies of any documentation you have received

Patient's details

(Please do not include the full name of the patient due to data protection requirements)
(DD/MM/YY)
IMPORTANT

If an incident takes place and you are unsure whether It is likely to give rise to a claim, you should notify us of the incident by completing this form.

If a claim is made against you and you have not notified us of the adverse incident, you will not be able to seek assistance.

If you need any help completing this form, please contact our medicolegal team for guidance on:

+44 113 243 6436