Health Minister Robin Swann has announced plans to improve the review process for serious adverse incidents (SAI) in Northern Ireland's health and social care system.
The reviews take place after unintended incidents of harm and ensure improvements are made.
The Regulation and Quality Improvement Authority (RQIA) was commissioned to examine the system's effectiveness. It found the process was not "sufficiently robust".
In the RQIA report, the independent body found that "neither the SAI review process nor its implementation is sufficiently robust to consistently enable an understanding of what factors, both systems and people, have led to a patient or service user coming to harm".
It added: "The reality is that similar situations, where events leading to harm have been inadequately investigated and examples of recognised good practice have not been followed, have been and are likely to be repeated in current practice."
It identified failures in the SAI procedure, including failures to:
- Answer patient and family questions.
- Determine where safety breaches have occurred.
- Achieve a systemic understanding of those safety breaches.
- Design recommendations and action plans to reduce the opportunity for the same or similar safety breaches in future.
Source: BBC News, 7 July 2022