'LEVEL THREE' Serious Adverse Incident (SAI) investigations are extremely rare in the Northern Ireland health service and relate to the most serious failings, including murder and abuse.
Documents leaked to The Irish News in August showed there are seven families in the north who have lost relatives to "homicides" and whose cases have been subject to health service probes due to suspected care failings.
Along with the James Hughes case, the other most high-profile SAI review relates to the brutal killings of pensioners Michael and Marjorie Cawdery.
The couple, who were both 83, were stabbed to death in their Portadown home in a "frenzied attack" by paranoid schizophrenic Thomas McEntee two years ago.
The Cawdery family demanded a fresh health service investigation into the deaths after describing an initial SAI probe by the Southern health trust as "shambolic" and "offensive".
Like the Hughes family, they were excluded from the initial review process.
The fresh probe found that the elderly couple's deaths could not have been predicted but could have been "avoided".
As a result of the Cawdery family's concerns, a separate confidential probe investigated the SAI reporting system for homicides in Northern Ireland and discovered it needed to be overhauled "as a matter of urgency".
It revealed there have been delays in seven different NHS investigations involving patient deaths over the past three years.
In August, the most senior figure in the north's health service, permanent secretary Richard Pengelly, apologised to the Cawdery family "on behalf of the entire health and social care system" and vowed to improve the SAI process for relatives affected.
The current SAI guidance, updated in 2016, states: "It is the role of the (SAI) chair to ensure engagement with families, that their views are sought, that support has been offered to them at an early stage and they have the opportunity to comment on the final draft of the report".
