AQW 45206/22-27


Mr Colin McGrath
Social Democratic and Labour Party
South Down


Tabled Date: 30/04/2026
Answered On Date: 20/06/2026
Priority Written: No


Question:
To ask the Minister of Health to detail (i) the recommendations of the Inquiry into Hyponatraemia Related Death (IHRD) which reference Serious Adverse Incidents and which his Department asserts have now been fully implemented; and (ii) the recommendations of the IRHD which reference Serious Adverse Incidents and which are fully implemented within his Department’s Framework for Learning and Improvement from Patient Safety Incidents.


Answer:
Five recommendations which reference Serious Adverse Incidents (SAIs) were assessed by the Department as actioned under Phase 1 of the Hyponatraemia Related Deaths (IHRD) implementation programme. This position was outlined in an update published by the Department in June 2023. The five recommendations are set out in Table 1 below.
Table 1
No
Recommendation
40
Learning and trends identified in SAI investigations should inform programmes of clinical audit.
62
Clinicians caring for children should be trained specifically in communication with parents following an adverse clinical incident, which training should include communication with grieving parents after an SAI death.
65
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
69(iii)
Trusts should appoint and train Executive Directors with specific responsibility for: Learning from SAI related patient deaths.
81
Trusts should ensure that all internal reports, reviews and related commentaries touching upon SAI related deaths within the Trust are brought to the immediate attention of every Board member.
The remaining 21 IHRD recommendations which relate to SAIs are under active consideration as part of the Department’s ongoing programme to redesign the extant SAI Procedure. These recommendations are set out in Table 2 below.
Further detail on the extent to which each of these remaining IHRD recommendations will be addressed through the SAI Redesign Programme will be available once I have considered and agreed the final strategic proposals.
Table 2
No
Recommendation
31
Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents (‘SAIs’)
32
Failure to report an SAI should be a disciplinary offence
33
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive
34
The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses
35
Failure to co-operate with investigation should be a disciplinary offence
37(i)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints
37(ii)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular families should be given the opportunity to become involved in setting the terms of reference for an investigation
37(iii)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular families should, if they so wish, engage with the investigation and receive feedback on progress
37 (v)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular families in cases of SAI related child death should be entitled to see relevant documentation, including all records, written communication between healthcare professionals and expert reports
37(vi)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular all written Trust communication to parents or family after a SAI related child death should be signed or co-signed by the chief executive
37(vii)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular families should be afforded the opportunity to respond to the findings of an investigation report and all such responses should be answered in writing
37(viii)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular family GPs should, with family consent, receive copies of feedback provided
37(ix)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular families should be formally advised of the lessons learned and the changes effected
37(x)
Trusts should seek to maximise the involvement of families in SAI investigations and in particular Trusts should seek, and where appropriate act upon, feedback from families about adverse clinical incident handling and investigation
38
Investigations should be subject to multi-disciplinary peer review
39
Investigation teams should reconvene after an agreed period to assess both investigation and response
42
In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families
66
Clinicians should be afforded time to consider and assimilate learning feedback from SAI investigations and within contracted hours
82
Each Trust should publish policy detailing how it will respond to and learn from SAI related patient deaths
83
Each Trust should publish in its Annual Report, details of every SAI related patient death occurring in its care in the preceding year and particularise the learning gained therefrom
91
The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information