Severity assessment code (SAC) 1 clinical incidents

SAC 1 clinical incidents are clinical incidents that have or could have (near miss) caused serious harm or death that is attributable to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.

Public hospital and health service notification of SAC 1 clinical incidents occurs via the Datix Clinical Incident Management System (CIMS). A number of User Guides are available to assist with use of Datix CIMS.

Private licensed and health care facilities and non-government organisations (in accordance with their licence or contract with WA Health) notify SAC 1 clinical incidents using the SAC 1 Clinical incident notification form (PDF 210KB) and sending it via email to

In WA, sentinel events are categorised as Severity Assessment Code 1 (SAC 1) clinical incidents. The reporting of SAC 1 clinical incidents is mandatory for:

  • public hospitals
  • all private licensed health care facilities
  • nongovernment organisations (in accordance with their license or contract with WA Health).

As outlined in the Clinical Incident Management Policy 2019 the key timeframes are:

  • to submit completed investigation reports which are due within 28 working days of notification to the Patient Safety Surveillance Unit
  • all SAC 1 recommendations must be both implemented and evaluated within six months (182 calendar days) of the investigation report submission
  • an evaluation of SAC 1 recommendations must also be forwarded to PSSU within those six months (182 calendar days) of the investigation report submission.

See the closing the loop page for more detail about the evaluation of recommendations.

CIM Policy Pack – Resources



More information

Patient Safety and Surveillance Unit

Last reviewed: 06-12-2023
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Patient Safety Surveillance Unit