Introduction

Society’s view of clinicians has recently undergone a sea change. This has followed from a series of high-profile medical disasters, which have received considerable media publicity. This has forced the present government and the NHS to be seen to be putting their house in order. Clinical governance became an integral part of the 1999 NHS Act. As a result, in the past two years a deluge of new guidance has been published and new institutions have been formed that have either begun to work or are about to do so. Clinical risk management, which is a significant component of clinical governance, requires untoward incidents to be reported. A common definition of an untoward incident is ‘an occurrence not in keeping with the routine care of the patient or the routine operation of the institution’.