Significant event analysis policy (gp)

1. What the regulation says

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Reg 17(1): the umbrella duty)

assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services) ... assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity. (Reg 17(2)(a) and (b): quality and risk)

maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided. (Reg 17(2)(c): accurate service-user record)

Regulation 20 adds the duty of candour that the SEA process must consider for qualifying events:

Registered persons must act in an open and transparent way with relevant persons in relation to care and treatment provided to service users in carrying on a regulated activity. (Reg 20(1): the headline duty)

As soon as reasonably practicable after becoming aware that a notifiable safety incident has occurred a registered person must (a) notify the relevant person that the incident has occurred in accordance with paragraph (3), and (b) provide reasonable support to the relevant person in relation to the incident, including when giving such notification. (Reg 20(2): the notification trigger)

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/17 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/20. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

You have to run effective systems and processes to comply with everything else in Part 3. The regulation lists six things those systems must enable in particular: quality assessment and improvement, risk management, accurate service-user records, accurate employment and management records, seeking and acting on feedback, and continually evaluating and improving how you process all this. If CQC requests a written report on quality and risk plus your improvement plans, you have 28 days from the day after the request.

Significant event analysis is one of the ways a GP practice meets this duty. Where an event qualifies as a notifiable safety incident under Regulation 20(9), which is the definition that applies to a GP practice, the separate duty of candour also applies: an unintended or unexpected incident that, in the reasonable opinion of a health care professional, appears to have resulted in death related to the incident, impairment lasting or likely to last at least 28 days, changes to the structure of the body, prolonged pain or prolonged psychological harm, or shortened life expectancy, or that requires treatment to prevent death or an injury leading to one of those outcomes. Where it applies, you must be open with the person as soon as reasonably practicable, give a truthful account, offer support, apologise, and follow up in writing.

3. Purpose

This policy sets out how the Practice records, reviews, learns from and closes significant event analysis records in primary care.

The Verivius platform calls these records incidents. Primary-care convention often calls the review process significant event analysis or SEA. This policy uses both terms so staff understand the mapping.

4. Scope

This policy applies to:

• clinical incidents and near misses
• significant event analysis records
• prescribing, referral, communication, result-handling and safeguarding events
• complaints that identify a patient-safety learning point
• events involving GP partners, salaried GPs, locum GPs, nurses, pharmacists, healthcare assistants, reception staff and managers
• private GP services and NHS-contracted GP services where the Practice provides them

The Practice records the event once and uses the SEA process to review it.

5. SEA review workflow

The Practice follows a documented SEA cycle for every event that meets the local review threshold.

5.1 Log the event

Staff record the event as soon as practicable after they become aware of it.

The record includes:

• what happened
• date and time
• patient involved where relevant
• staff involved
• immediate action taken
• known harm or risk of harm
• whether urgent escalation is needed
• whether duty of candour may apply
• whether external reporting may be needed

Staff record facts and avoid blame language.

5.2 Triage the event

The Clinical Lead or delegated senior person triages the record.

Triage considers:

• severity
• likelihood of repeat
• actual or potential harm
• patient-safety risk
• safeguarding risk
• complaint link
• data-protection link
• staff support needs
• external notification or reporting routes

The triage decision records whether the event needs immediate action, full SEA discussion or closure with documented learning.

5.3 Review the event

The SEA review identifies what happened and why.

The review considers:

• timeline
• staff account
• patient account where appropriate
• relevant records
• protocols in place at the time
• workload, staffing and communication factors
• prescribing, referral or result-handling factors
• whether the event was isolated or part of a pattern
• whether the Practice needs external advice

The review records contributing factors, learning and actions.

5.4 Close the event

The Clinical Lead closes the SEA record only when:

• immediate safety action is complete
• learning has been agreed
• improvement actions have owners
• patient or family communication has been considered
• duty of candour has been considered
• external reporting has been completed or ruled out
• the governance group has reviewed the record where required

The closure note records the reason for closure and any remaining monitoring.

6. SEA meeting cadence

The Practice uses a quarterly SEA review meeting as the Verivius default unless current CQC, NHS England, GMC, contract or local governance source material requires a different rhythm.

The meeting:

• reviews open SEA records
• reviews closed SEA records from the quarter
• checks overdue actions
• identifies repeat themes
• checks whether learning was shared with staff
• agrees whether a clinical audit or policy change is needed
• records attendance and decisions

The Practice does not describe the quarterly cadence as regulator-mandated unless the current source says so.

7. Learning loop

The Practice shares SEA learning in a way that matches the risk and audience.

Learning may be shared through:

• clinical meeting
• staff meeting
• reception-team briefing
• prescribing meeting
• safeguarding supervision
• one-to-one staff support
• policy update
• clinical audit
• patient-facing communication where appropriate

The Practice checks whether learning has changed practice. Learning is not complete until the action has been implemented and reviewed.

8. Responsibilities

• Registered Manager: owns this policy, ensures the SEA process is governed and signs off annual review.
• Clinical Lead: owns day-to-day SEA quality, triage, review standards and closure decisions.
• Lead GP or GP Partner: reviews doctor-only clinical judgement, prescribing and referral events where needed.
• Practice Manager: supports records, meeting agendas, action tracking and staff communication.
• All staff: record events promptly, take immediate safety action within role and contribute honestly to review.

8.1 Training and competence

At induction, every worker is shown how to log an event, who triages it and how urgent concerns are escalated when the Practice is closed or the usual lead is unavailable.

People who chair or lead SEA reviews receive training in proportionate, systems-based review, duty of candour, patient and staff involvement, confidentiality and action design. Before a person leads a review alone, the Clinical Lead samples one completed review against this policy and records sign-off in the training matrix.

Locums and temporary staff receive the same reporting route in their first-shift information. The Practice does not assume that previous NHS or primary-care experience means they know the local process.

9. Recording requirements

The Practice keeps the following records:

• incident or SEA record
• triage decision
• review notes
• patient communication record
• duty of candour assessment
• external reporting decision
• improvement actions
• action completion evidence
• SEA meeting minutes
• learning shared with staff
• audit record

Records are kept in the Practice governance records and are available for internal review, CQC review and external review where required.

10. Audit cadence

The Practice uses the following Verivius default audit rhythm unless current source material requires more frequent review:

• Monthly: the Clinical Lead reviews open SEA records, overdue triage and urgent actions.
• Quarterly: the SEA meeting reviews records, themes, learning and action closure.
• Annually: the Registered Manager audits the SEA process against this policy, CQC source material and GMC source material.

Audit findings are recorded as improvement actions with an owner and review date.

11. Version control and review date

The Practice keeps a controlled copy of this policy. The footer or document-control table records:

• policy owner
• version number
• date approved
• next review date
• changes made since the last version
• source material checked during the review

12. Related policies and records

• Incident register
• SEA meeting minutes
• Improvement action register
• Complaints policy
• Duty of candour policy
• GP safeguarding policy
• GP safe prescribing and high-risk medicines policy
• GP patient data and information governance policy
• Incident reporting, investigation and learning policy
• Action plan and improvement tracking policy
• Clinical audit schedule

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

13. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

• CQC Regulation 17: Good governance
• CQC Regulation 20: Duty of candour
• CQC inadequate SEA example, updated February 2026: https://www.cqc.org.uk/guidance-regulation/gps/what-does-inadequate-practice-look-like-examples/inadequate-example-significant-event-analysis-sea
• GMC professional candour guidance
• NHS England Primary Care Patient Safety Strategy, LFPSE and PSIRF material where applicable to the Practice's contracts and reporting duties
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (https://www.legislation.gov.uk/uksi/2014/2936/regulation/17)

14. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

15. Document control

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.