Serious Untoward Incidents

Serious Untoward Incidents

The healthcare sector operates under intense public and media scrutiny. When things go wrong, inevitably the public want to know why. Serious Untoward Incidents (SUIs), in particular, are potentially a rich source of copy for the media.

An SUI causes, or has the potential to cause, serious harm to patients, healthcare staff or the public. It may be clinical or non clinical, but it is essential that, when an SUI occurs, organisations not only take action to minimise damage to patients, employees and the public, but also re-evaluate policies and procedures to prevent a recurrence.


  • Deaths which are sudden, unexpected or due to suicide or homicide.
  • Death or injury occurrences where policies or procedures were not followed.
  • Serious complaints or allegations made against a healthcare professional.
  • Equipment failures or misuse.
  • Failures in systems and procedures.


All healthcare organisations have strategies for handling SUIs. Iodem works within these strategies, using an Investigative Tool Kit which was specifically designed to support in-depth, insightful investigations that ensure the learning to prevent a recurrence is maximised, it's design also ensures that our investigations cover key elements of legislation such as HSG(94)27.


The Iodem tool kit can be applied to all stages of an investigation, including:-

  • Initial service management reviews.
  • Internal NHS Trust investigations.
  • Independent investigations.

For maximum effectiveness, it is operated by Grey Panthers, senior individuals from the healthcare industry with significant experience of clinical trouble shooting, whose primary role is to identify what happened, track down the root cause of the problems and provide solutions. They are supported by a dedicated team of regulatory lawyers, police trained senior investigators and risk managers whose experience supplements that of their clinical colleagues.

Iodem’s unique blend of skills and experience not only allows it to undertake investigations to a very high standard, but to conduct them sensibly, with a view to preserving working relationships and bridging gaps where appropriate.

Iodem’s reports identify the factors contributing to the critical incident and highlight how the chance of recurrence can be minimised.

Our reports constitute a thorough audit trail of the conduct of the investigation and our experienced in-house legal team will ensure they will withstand legal examination.


Iodem will manage all aspects of the independent investigation of serious patient safety incidents, thus freeing up management time which would otherwise be absorbed by handling the time intensive, day to day issues which are part of the investigation process.

Speedy, discrete and clinician led, the service is designed to get to the root cause of the problem, identify the issues and provide a framework to address the concerns which have been raised. It includes:-

  • Advice and support in assembling and supporting a clinical review panel.
  • Complete project management of an investigation including detailed budgets and reporting schedules.
  • Establishing a bespoke multi-disciplinary investigation team with clinical expertise from the relevant specialities and police trained investigators.
  • Liaison with all individuals involved in the incident including staff witnesses, family members, perpetrators, police and coroners.
  • Root cause analysis to identify the factors which contributed to the critical incident.
  • Collating and documenting evidence in accordance with legal requirements - including safeguarding where necessary.


We have the expertise to deliver bespoke training as a supplementary service where it is identified as part of a solution to any issues revealed or highlighted by the investigation.

Alternatively, we can provide training, coaching or mentoring as a separate service that offers a cost effective method of updating skills. We can either develop and deliver a programme at our own premises or at a venue nominated by the client.

Copyright © 2009 Iodem Health. All rights reserved. Email: [email protected] | Disclaimer Created by HPM Group »