2023/24 review: Serious Incidents

We require establishments in several sectors to report serious incidents that occur in areas covered by their licence. This is to ensure we are sighted on incidents and can ensure they are carefully investigated.

Once an incident is reported to us, we check that it meets our requirements of a reportable incident. We subsequently seek to understand what immediate actions have been taken and work with establishments to reduce the likelihood of the incident being repeated.

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Number of closed incidents per sector

Sector

Q1

Q2

Q3

Q4

2023/24 total

2022/23 total

2021/22 total

Human application

59

91

107

49

306

218

238

Post-mortem

48

37

36

41

162

146

104

Organ donation and transplantation

18

34

23

8

83

70

61

Total

125

162

166

98

551

434

403

 

In 2023/24, we were alerted to 551 reportable incidents. Our establishments reported 306 serious adverse events and reactions (SAEARs) in the human application sector, 162 HTA Reportable Incidents (HTARIs) in the post-mortem sector and 83 SAEARs in the organ donation and transplantation sector. Since the start of the strategy, the number of closed incidents across all three sectors have increased. We will continue to work with stakeholders to encourage proactive incident reporting.

One of the very helpful things [the HTA] do is share examples of the most common adverse incidents in that sector, and then you can carry out risk assessments to make sure that your processes are such that you would avoid having similar incidents. 

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