What are Untoward Incidents in Health and Social Care?

Untoward incidents are unexpected or unplanned events which could, or do, result in harm, loss, or risk to patients, staff, or visitors within health and social care settings. Sometimes, these are referred to as adverse incidents or adverse events, but the term “untoward incident” is commonly used in the UK to describe situations which fall outside normal standards of care or pose a threat to safety and wellbeing.

Across all kinds of care provision – hospitals, care homes, clinics, home care, GP surgeries, and mental health services – untoward incidents can threaten the safety of individuals and the quality of care provided. Every organisation delivering care has a duty to recognise, report, and learn from untoward incidents. This focus helps prevent repetition and protects those in receipt of care.

Defining Untoward Incidents

An untoward incident is any event which:

• Could have or did cause harm, injury, or distress,
• Occurred unexpectedly or was not intended,
• Required a change in planned treatment or intervention.

This could refer to a one-off mishap or signal an ongoing problem in care delivery.

Examples include:

• A patient fall causing injury
• A medication or prescription error
• Failure to monitor vital signs at required intervals
• Patient absconding or going missing from care
• Outbreak of infection within a ward
• Self-harm or attempted suicide in mental health settings
• Staff member sustaining an injury at work
• Fire, flood or similar incidents affecting service provision
• Breach of patient confidentiality
• Verbal or physical aggression affecting staff or service users

These incidents are not always the result of human error. System failures, lack of resources, poor communication, or environmental factors also play a part.

Why Reporting Matters

Open reporting of untoward incidents creates opportunities for learning and service improvement. Under UK law, statutory requirements such as the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, oblige providers to notify relevant authorities (for example, the Care Quality Commission or CQC) about specified incidents.

The aims of reporting untoward incidents include:

• Protecting safety of everyone using or working in services
• Helping to understand how and why something went wrong
• Supporting learning so similar events do not happen again
• Improving transparency and accountability
• Meeting legal and regulatory requirements

Staff may find reporting challenging, especially if they are involved in the incident. A “no blame” approach is encouraged to help staff disclose mistakes or near-misses without fear of punishment unless there has been wilful neglect or deliberate harm.

Types of Untoward Incident

Untoward incidents in health and social care can be divided into several types. Each carries different levels of risk and requires different responses.

Clinical Incidents

These are directly related to treatment, diagnosis or clinical procedures.

• Incorrect medication or dosage
• Infection linked to invasive procedures
• Misdiagnosis or delayed diagnosis
• Incorrect use of equipment

Patient Safety Incidents

These involve risks to the safety or welfare of people using services.

• Falls resulting in injury
• Pressure sores
• Self-harm in psychiatric units
• Patients leaving without authorisation

Security Incidents

Here, the event affects security or property.

• Theft or loss of drugs or sensitive documents
• Intruder or unauthorised visitor
• Damage to premises or vehicles

Information Governance Incidents

These cover breaches of data protection and privacy.

• Loss or theft of medical records
• Sending confidential information to the wrong recipient
• Unauthorised access to electronic systems

Health and Safety Incidents

Staff or visitors can be affected by:

• Manual handling injuries
• Exposure to hazardous substances
• Physical assaults or verbal abuse
• Equipment failures

Causes of Untoward Incidents

Understanding what led to an untoward incident is the first step to prevention. Often, incidents have more than one cause, and contributing factors may interact.

You might see these causes:

• Poor communication between staff or teams
• Inadequate training or supervision
• Staff shortages or work pressures
• Environmental hazards, such as slippery floors
• Faulty or outdated equipment
• Gaps in procedures or risk assessments
• Lack of understanding about policies or protocols

Sometimes, weaknesses in organisational culture, such as resistance to change or unwillingness to report problems, contribute to recurrence.

The Impact of Untoward Incidents

Untoward incidents have a far-reaching impact. These events affect the people receiving care, their families, staff, and the organisation as a whole.

Impact on Service Users

• Physical injuries or prolonged suffering
• Psychological trauma or reduced trust in care
• Longer stays in hospital or delayed recovery
• Feelings of being unsafe or neglected

Impact on Staff

• Emotional distress or anxiety
• Damage to professional reputation
• Fear of blame or disciplinary action
• Loss of job satisfaction or morale
• Possible legal consequences in cases of gross negligence

Impact on Organisations

• Legal claims or financial penalties
• Poor rating by regulatory agencies (such as CQC)
• Reduced public confidence
• Disruption of service delivery or reputation damage

Learning from these situations helps prevent repeats and builds a safer, more supportive working environment.

Identifying Untoward Incidents

Spotting untoward incidents relies on vigilance and an open culture where staff, patients, and even visitors are encouraged to raise concerns. Recognition comes from:

• Direct observation by staff or managers
• Reports from those receiving care or family members
• Data analysis – for example, unexplained rise in falls or infections
• Audits or quality checks
• Complaint investigations
• Feedback from incident debriefs or handover meetings

Organisations often use risk management software or reporting systems to log and track incidents, near misses, and trends.

Responding to Untoward Incidents

The immediate response is always to protect those affected from further harm and to provide any necessary treatment. Following that, the focus shifts to managing the situation and learning from what happened.

Main response steps:

• Make the area safe and provide medical attention where needed
• Notify senior staff and complete an incident report
• Secure evidence if relevant (for example, preserving a faulty piece of equipment)
• Support service users and staff involved
• Begin an internal investigation or root cause analysis

Records need to be accurate, factual, and completed in a timely manner. Managers may need to notify external agencies, such as the CQC, police, or safeguarding teams, especially if a serious injury, death or abuse is involved.

Duty of Candour

The duty of candour is a legal requirement for openness and honesty when untoward incidents cause harm. Organisations must inform the person affected (or their representative) as soon as possible, explain what happened, apologise, and provide support.

Duty of candour develops trust and helps organisations take responsibility when things don’t go as planned.

Preventing Untoward Incidents

Risk management and quality improvement activities are designed to minimise the chance of untoward incidents. Prevention begins with strong systems and a safety-first culture.

Prevention strategies:

• Clear protocols for high-risk activities
• Ongoing staff training
• Risk assessments for both people and environments
• Regular equipment checks and maintenance
• Sufficient staffing levels
• Good communication and teamwork
• Involving those who use services in care planning

Learning from previous incidents is key. Organisations often use significant event analysis, root cause analysis, and regular reviews of data to pick up patterns and make changes.

Learning from Experience

Each untoward incident offers information to help prevent future problems. Organisations should create a culture where lessons learned are widely shared, not hidden.

They might:

• Conduct “learning lessons” meetings after incidents
• Produce anonymised case studies
• Update policies and procedures
• Deliver targeted training in areas where weakness is noted

Barriers to learning include fear of blame or the feeling that nothing will change. Strong, visible leadership and an open, supportive culture are helpful in breaking down these barriers.

The Role of Regulatory Bodies

Health and social care providers in England must follow regulatory guidance from bodies like the Care Quality Commission, the Nursing and Midwifery Council, and the General Medical Council. These bodies expect services to manage and learn from untoward incidents and may inspect incident records during visits.

They want to see:

• Timely and accurate reporting
• Thorough enquiries into what happened
• Evidence that care has changed as a result

Services unable to show this may face sanctions or lower ratings.

Supporting Those Involved

Untoward incidents can be distressing. Organisations should recognise the emotional toll on everyone involved.

Support may include:

• Psychological support or counselling
• Immediate debriefings for staff
• Regular supervision and reflective practice
• Honest communication with people affected and their families

Providing clear guidance and reassurance helps maintain morale and confidence.

Final Thoughts

Untoward incidents are unexpected events which threaten the safety or wellbeing of those in health and social care. Recognising, reporting, and learning from these incidents helps protect people and improves the quality of services offered. A strong safety culture, backed up by effective systems, legislation, and supportive leadership, helps keep everyone safer and more confident in the care they receive or give.