Using Quality Improvement to improve serious incident reporting in the English NHS

Timely completion of serious incident reports is crucial for patient safety and regulatory compliance. Delays hinder organisational learning and compromise patient outcomes. Between May 2021 and April 2022, East London NHS Foundation Trust (ELFT), a provider of mental health, community health and primary care services to approximately 1.8 million people across London and Bedfordshire, faced a significant backlog of serious incident reports. Completion times averaged 208 days-well beyond the 60-day target set by NHS England at the time.

A quality improvement (QI) initiative employing structured methodologies, including the ELFT Sequence of Improvement, statistical process control, Ishikawa analysis, a driver diagram and plan-do-study-act cycles to diagnose and address process inefficiencies.

Three main change ideas were tested and implemented: concise reporting templates to streamline documentation, a caseload tracker for real-time monitoring and team escalation meetings to improve communication and accountability.

These interventions led to a 65% reduction in average completion time, decreasing from 208 days to 74 days. Additionally, staff collaboration and workflow efficiency improved, fostering a culture of continuous improvement, continuous learning and accountability.

This project demonstrates the effectiveness of structured QI methodologies in improving serious incident reporting. The implemented changes are sustainable and provide a scalable model for other healthcare organisations aiming to enhance patient safety and compliance. Future work will focus on embedding these improvements into routine practice and exploring their impact on broader organisational learning.