INCIDENTS AND SERIOUS INCIDENTS POLICY
Policy Lead: / Associate Director, Corporate GovernanceRatifying Group: / Board of Directors
Status:
Reference No
Signed: ______
Dame Ruth Runciman, Chairman
Date: ______
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Incidents and Serious Incidents – draft v05
Contents
1 Key points3
2 Purpose and scope3
3 Responsibilities of key staff3
4 Definitions used – an explanation of terms4
5 Policy
5.1Treatment of incidents and Serious Incidents4
5.2Incidents and Serious Incidents Procedures4
5.3Support for users (Being Open) 4
5.4Disclosure of information to service users regarding incident
investigations5
5.5Support for staff5
5.6Reporting to the Board of Directors5
5.7Reporting to external agencies5
5.8External Independent investigations5
5.9Whistle Blowing6
5.10Never Events6
5.11Treatment of staff statements and interview notes6
5.12Major Clinical Incidents6
5.13Learning form Incidents and Serious Incidents6
5.14Non-Executive Director chaired Panels of Inquiry6
5.15Safeguarding incidents6
5.16Generalissues7
6 Monitoring compliance and effectiveness of this policy7
7 References7
APPENDICES
Appendix AResponsibilities of staff and timescales
Appendix BSI grading system
Appendix CIncident Procedure
Appendix DSerious Incidents Procedure
Appendix EExternal Notification Requirements
Appendix FExternal independent investigations
Appendix GMajor Clinical Incidents
Appendix HGeneral Issues
Appendix IMonitoring Compliance and Effectiveness
Appendix JReferences
Appendix KEquality Impact Assessment
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Incidents and Serious Incidents – draft v05
1 KEY POINTS
1.Any incident or near miss will be dealt with immediately by staff. The person discovering the incident or near miss must take immediate action to deal with the situation.
2.The person in charge of the area must be informed of the incident or near miss as quickly as possible. That person must decide whether further immediate action is required.
3.The incident or near miss must be reported by staff on the Datix incident reporting system.
4.Serious incidents must be notified to HQ within 4 hours (to the On Call Manager out of hours) and an Initial Management Review completed within 72 hours.
5.Serious incidents may be subject to further investigation by Root Cause Analysis.
2 Purpose and scope
The purpose of the policy is:
- to provide a uniform approach to the reporting, management, investigation and learning in relation to Serious Incidents (SIs) across the Trust;
- to ensure that recommendations are identified and implemented to prevent the recurrence of such incidents.
3Responsibilities of key staff
The Board of Directors has responsibility for the approval of this policy. In discharging that responsibility, it will ensure that there are adequate governance arrangements in place for the effective reporting, management, investigation and learning from serious incidents.
The Director of Nursing and Operations is the Executive Director with Board level responsibility for incidents and SIs. He/she has responsibility for the review and investigation of all SIs including determining whether an event is an SI and its concurrent grading.
The Associate Director, Corporate Governance is responsible for monitoring that the Trust complies with the requirements of this policy and for the day to day management of this area.
The Trust Serious Incidents Manager is responsible for the administration of serious incidents matters and liaising with staff / managers regarding the completion of investigations and action plans.
Ward/Team managers and Sector/Service Managers are responsible for the reviewing of incident reports and determination of any further investigation or action.
It is the responsibility of all staff to report incidents and near misses involving service users, staff and others using the electronic incident reporting system (Datix).
Further specificresponsibilities of staff in relation to SIs are shown on the table at Appendices A and G.
4Definitions used
An incident is any event that has given or may give rise to actual or personal injury, patient dissatisfaction, or to property damage or loss. For the purpose of this policy an incident includes, but is not limited to, accidents, fires, violence, breaches of security, lost and or misused confidential information (including both electronic and paper records), infection control, clinical errors and illegal acts.
A serious incident occurs where an incident has serious outcomes and requires formal investigation.
A near miss occurs where an incident has the potential to cause injury, harm or disruption however the problem was identified and rectified such that any effect was avoided.
A grading system is used to classify the seriousness of an incident. Those classified as level 1 or 2 are defined as incidents and those graded 3, 4 or 5 are serious incidents (see Appendix B).
5 Policy
5.1Treatment of Incidents and Serious incidents
The Trust takes all incident and serious incidents seriously and requires all staff to comply with the requirements of this policy.
5.2Incidents and Serious Incidents Procedures
Incidents must be reported and managed in accordance with local procedures operating within Mental Health and Allied Services, Camden Provider Service and Hillingdon Community Health. The key principles of the reporting process are attached inAppendix C.
Serious incidents must be reported and managed using the procedure attached inAppendix D.
5.3Support for users (Being Open)
The Trust has developed a Being Open policy which outlines the ways in which it supports service users and carers/families through the provision of information. Following a serious incident, Service Directors will nominate a senior clinician or manager who will act as a support person to the service user or carer/family and be a focal point for contact and information relating to the incident, the subsequent investigation and feedback on any action taken. The Trust has developed a protocol for Being Open with patients which needs to be followed (hyperlink).
5.4Disclosure of information to service users regarding incident investigations
Service users (or carers/relatives, where appropriate) should be provided with information regarding any incident or SI about which they are subject. In relation to SIs, service users or the nearest relative, as appropriate, should also be offered feedback on the findings of the investigation into the incident and, if they request it, a copy of the anonymised investigation report.
5.5Support for staff
When a traumatic / stressful incident occurs there can be significant impact on staff who were involved in, or who witnessed, the incident. Like victims and families, staff will want to understand what happened, why it happened and what can be done to prevent it happening again. The Trust has developed a Policy on Supporting Staff, the contents of which should be followed (hyperlink).
The Trust has a duty of care to its staff, which includes the provision of support to those involved in incidents. All members of staff are entitled to this support.
The purpose of this policy is to ensure that appropriate and suitable resources and support are identified to staff involved in a potentially distressing incident, complaint or claim and to reduce the likelihood of staff being absent from work or leaving as a consequence of poor experiences following a potentially distressing incident, complaint or claim.
5.6Reporting to the Board of Directors
The Board of Directors will receive a report at each meeting on the level 5 SIs that have occurred since the previous meeting. The Board 4will also receive reports of Panels of Inquiries and independent inquiry reports on homicides involving CNWL patients.
5.7Reporting to external agencies
Details of patient safety incidents will be reported to the National Patient Safety Agency via the National Reporting and Learning System. Details of incidents involving security matters and assaults on staff will be reported to NHS Protect. Serious incidents graded level 5 will be reported to the relevant PCT and NHS London. Other reporting arrangements exist and these are summarised in Appendix E.
5.8External Independent Investigations
There are occasions when external independent investigations may be carried out. Is such circumstances, the guidance at Appendix F should be followed.
5.9Whistle Blowing
Whilst staff are expected to report incidents using normal reporting systems, there may be circumstances when they feel unable to do so. The Trust has a Whistle Blowing Policy and staff can raise concerns via that system (hyperlink).
5.10Never Events
The NPSA has issued guidance on Never Events. These are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. All patient safety incidents are monitored and if a never event occurs it will be identified as such and treated as a serious incident.
5.11Treatment of staff statements and interview notes
Statements of staff and notes of interviews conducted as part of the investigative process are to be treated as confidential. This is to promote the cooperation of staff with the investigation. Knowledge of public disclosure of such documents could otherwise inhibit staff from discussing events as openly as necessary with investigative staff.
5.12Major Clinical Incidents
In the event that a major clinical incident takes place, it may be necessary to establish arrangements to deal with multiple enquiries from patients. In such circumstances, the arrangements set out in Appendix G must be followed.
5.13Learning from Incidents and Serious Incidents
It is important to learn lessons from individual incidents and SIs and where possible to identify Trust-wide learning. The Trust has developed a Learning Protocol (hyperlink) which must be followed to ensure such learning is achieved alongside that relating to complaints, PALS and legal claims. Reports of aggregated learning will be presented to the Board.
5.14Non-Executive Directorchaired Panels of Inquiry
When incidents relating to homicides and on ward suspected suicides take place, a Non-Executive Director chaired Panel of Inquiry will normally be established. If after discussion between the Chairman and Chief Executive it is agreed that an alternative approach should be adopted, the rationale for such a decision will be reported to the next meeting of the Board of Directors.
The report of an investigation conducted by a NED chaired panel of Inquiry will be submitted to the Board of Directors for approval.
5.15Safeguarding incidents
Investigations into serious cases involving safeguarding (adults and children) are subject to London-wide procedures. These should be notified to the Associate Director, corporate Governance and the investigation report and action plan monitored in accordance with serious incidents procedure.
5.16General Issues
Guidance on the following general issues may be found at Appendix H
- Disciplinary action
- Inquests
- Media interest
- Investigating SIs that affect other organisations
- Incidents where a police investigation is in progress
- Incidents which are the subject of a complaint from a service user or carer or subject to a claim against the Trust
- Child Protection cases
- Variation from this policy
6 Monitoring compliance and effectiveness of this policy
A sample of incident and serious incidents will be analysed every six months to assess compliance with this policy.
A report on the outcome of these reviews will be reported to the Incidents and Serious Incidents Group with a plan for any consequent action required. The results will also be reported to the Organisational Learning Group to consider what lessons may be learned to improve the process in the future.
Details of the reviews are shown at Appendix I
7 References
A list of related documents is shown at Appendix J.
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Incidents and Serious Incidents – draft v05