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 800 616 7055.

Your details

Title

First name

Surname

Membership number

Telephone number

Email address

Your country of practice

Details of adverse incident

Date the adverse incident occurred

Time of the adverse incident

Date you became aware that the adverse incident occurred (if different from above)

Where did the adverse incident take place?

Enter the relevant address

The name(s) and role(s) of anyone else present when the adverse incident took place

(please write each name on a separate line)

Has an allegation, complaint or claim been made against you or the organisation?

If yes, please provide details and copies of any documentation you have received

Please provide details of the event or circumstance that may give rise to claim, complaint or allegation against you

Please upload any relevant supporting documentation

Permissible formats: jpg, jpeg, png, gif, bmp, pdf, doc, docx, ppt, pptx, ppsx, xls, xlsx

Patient's details

Initials of the patient

(Please do not include the full name of the patient due to data protection requirements)

Patient's gender

Patient's date of birth

(DD/MM/YY)

Does the patient have a reference number at the practice / hospital? If yes, please provide it

Select choices

I confirm I have only provided the information specifically requested and have not provided any additional details which would allow MPS to identify an individual patient

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.

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ADVERSE INCIDENT REPORT

Your details

Details of adverse incident

Patient's details

IMPORTANT