Martin Bromiley, March 2012 –

I remember Clare Bowen whose daughter Bethany tragically died during an operation telling me that one of the worst things in the months afterwards was that whenever she called the hospital to discuss her daughter’s death they would refer bureaucratically to “the SUI”.  Clare had to remind them that “it” wasn’t an SUI, but her daughter.  If you haven’t read about Clare’s story please have a look at

An SUI, “serious untoward incident”.  These incidents are investigated internally by the hospital where the problem occurred to enable lessons to be learned.  Those of you who’ve read my previous blogs will know my concerns about SUIs.  They aren’t independent, they try to learn lessons and determine what to do with those involved (you’ve got to split the process, these are two issues for two different groups of people); and of course it’s very rare that details are openly published so that others across the country can learn.

But, the DoH is very good with ensuring they’re completed on time.  The DoH files are full of SUIs that have been completed within the timescales specified.  How can you have a deadline when the complexity of required investigation is unknown?

In December 2010 the Clinical Human Factors Group ( agreed with the DoH that it was time to do something about human factors and in traditional response a “working group” was formed.  However this working group has really done some work, and gone beyond its remit which was to advise on how we could start to embed human factors in healthcare.  It’s currently feeding back its recommendations, but just as importantly it’s done quite a few things to get the embedding underway.

One important question was how can the NHS learn from incidents?  We decided to use just one type of event to look at, wrong site surgery, a “never event”.  We then reviewed the DoH files to see firstly if human factors were present in the incidents, and secondly to see what this review process told us about learning from SUIs and other reviews.

The outcome is no surprise.  The report is now freely available (download it from the CHFG website) and human factors was writ large in every event, at multiple levels.  But it also demonstrates that by applying a human factors lens to the analysis it highlights aspects of behaviour and the system that are either not seen or given insufficient weight through our current reporting approach.  And not only that, but it also produced a valuable tool to help learning which genuinely and professionally addresses issues in a way that can be acted upon by the frontline and management.

Later this year more work will be published on our report, but we’re trying to be creative here.  In combination with a number of people and organisations we’re hoping to produce a training DVD, as well as produce “discussion cards” that can be used at the frontline to promote reflection and learning from others – before it happens to you.

However, despite all this it’s my belief that until we have a trial of independent investigation for the most serious of incidents, (i.e. quality not quantity of investigations is critical) that SUI reports will disappear into a filing cabinet.  And SUIs will still fail to capture the real lessons.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.