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Medicolegal advice +44 113 243 6436

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.

If you need any help completing this form, please contact our medicolegal team for guidance on +44 113 243 6436.

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
Please upload any relevant supporting documents
Permissible formats: jpg, jpeg, png, gif, bmp, pdf, doc, docx, ppt, pptx, ppsx, xls, xlsx

Patient's details

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

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

If a claim is made against you as an individual complete as many details as possible, and provide us with any associated documentation that you feel we should be aware of.

If reporting on behalf of a corporate member, please ensure you’re authorised to do so as we cannot accept reports from unauthorised contacts.  If a claim arises and you have not notified us of the adverse incident you will not be able to seek assistance.