Clinical Incident Reporting

This form is to be used to report any incidents or concerns from eConsult or eTriage reports you have received. It enables our clinical development team to conduct an analysis of the event and recommend any changes to the system to reduce clinical risk if appropriate.

Please provide details of the event below and append an anonymised copy of the full eConsult or eTriage report in question.

This form is for clinical incidents only: A clinical incident is any unplanned event which causes, or has the potential to cause, harm to a patient. If your request is for anything else please contact: practice.support@econsult.health (for Primary Care support) or hospital.support@econsult.health (for Secondary Care support) or follow your usual protocol.

Under Information Governance rules please do not disclose any patient identifiable information on this report or in any information you send to eConsult Health Ltd.

How to anonymise an eConsult report

Watch the quick video below or download our guide

How to anonymise an eConsult or eTriage report Download

Clinical Incident Reporting – Complete below

Location of incident (i.e. GP Surgery or Emergency Department)*
ICB name*

Please enter the name of your ICB.
GP surgery name*
NHS Trust name*
Please enter the name of the NHS Trust.
Emergency Department name*
NHS Trust or ICB name*

Please enter the name of the NHS Trust or ICB.
UCC name*
Outpatients Specialty*
Date of incident*
DD slash MM slash YYYY
Time of incident*

: Hours

Minutes

AM/PM
Which clinical template did the patient complete?*

For example: "general advice" "depression" or "cold or flu"
eConsult reference number*

This is the 8 character alphanumeric code located on the eConsult PDF 'e.g.eConsult reference number for this request: 8F8D9AB3'
Patient age*
Please enter a number from 0 to 150.
Patient gender*
- Female
- Male
Description of the incident*
Severity of harm caused*
Major - Permanent life-changing incapacity, death, severe injury from which recovery is not expected in the short term or severe psychological trauma
Considerable - Significant psychological trauma, severe injury or severe incapacity from which recovery is expected in the short term, minor injury or injuries expected
Significant - Minor injury or injuries from which recovery is not expected in the short term, minor injury from which recovery is expected, minor psychological upset or inconvenience
Minor - Minor injury from which recovery is expected, minor psychological upset
If harm was caused, please provide a description
optional*
Timeline of the response and assessment by the team*
For example, the date and time the report was reviewed and the patient was assessed
Action taken by the team and patient outcome (if known)*
For example, treatment given, diagnosis (if known) or onward referral.
Hidden
Action taken by the team and patient outcome (if known)*
Hidden
Outcome of patient's consultation*
Your name and job title*
Your contact email*
Your contact number*
Please upload anonymous copy of the eConsult*
Drop files here or

Max. file size: 64 MB.
Please upload anonymous copy of the eTriage*
Drop files here or

Max. file size: 64 MB.
Please confirm the document you have uploaded does not contain PID or sensitive information*
- Yes - There is no PID or sensitive information included