NUH 414 SUI Policy Final 22 10 07 by S0rWomUO

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									SERIOUS UNTOWARD INCIDENT POLICY AND PROCEDURES

                  DOCUMENTATION CONTROL

Reference

Date Approved

Approving Body                 Trust Board

Implementation Date            November 2007

Version                        1
Supersedes                     Nottingham City Hospital
                               Policy for The Management of
                               Untoward Incidents, including
                               serious untoward incidents
                               2004
                               Queen’s Medical Centre
                               Procedure for Reporting of
                               Serious Untoward Incidents
                               2005
                               Clinical and Non-Clinical
                               Hospital Staff
                               Organisational Risk Committee
Consultation Undertaken        Clinical Risk Committee
                               Risk Management Committee
                               Directors’ Group

Target Audience                All NUH staff

Supporting Procedure(s)        Refer to section 12

Review Date                    November 2008

Lead Executive                 Medical Director

Author/Lead Manager            Medical Director
                               Executive Business Manager /
Further Guidance/Information
                               Head of Governance x. 61714
                                          CONTENTS

Section        Title                                                     Page
1              Introduction                                                 3
2              Policy Statement and Aims                                    3
3              Scope                                                        5
4              Definitions                                                  5
5              Roles and Responsibilities: ‘what to do’
5.1                All staff                                                7
5.2                Responsible Manager                                      7
5.3                Directorate Team, Head of Service or Senior              8
                   Manager
5.4                Duty Director                                           9
5.5                Responsible Director                                    9
5.6                Executive Business Manager, Head of                     10
                   Governance
5.7                Medical Director                                        11
5.8                Chief Executive                                         11
5.9                Committees                                              11
5.10               Trust Board                                             12
6              Internal Inquiry and Report
6.1                Serious Untoward Incident Inquiry Team (SIT)            12
6.2                Conduct of the Inquiry                                  14
6.3                Inquiry Report Format                                   15
6.4                Sharing the Report and Lessons Learned                  16
6.5                Action Plans and Audit                                  17
7              Analysis of SUI Themes & Trends                             18
8              Monitoring                                                  18
9              Training                                                    19
10             Records Management & Confidentiality
10.1               Document Storage and Confidentiality                    19
10.2               Disclosure of SUI Information (FOI)                     20
11             Equality and Diversity Statement                            22
12             Supporting NUH Policies and Procedures                      22
13             References                                                  23
App 1          Criteria for Reporting an SUI to PCTs & NHS EM              24
App 2          Governance Team Contact Numbers                             29
App 3          Committee Terms of Reference                                30
App 4          Guide to the Inquiry Process                                37
App 5          Standard Report Format                                      40
App 6          Employee Record of Having Read Policy                       41


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1. INTRODUCTION

Nottingham University Hospitals NHS Trust [NUH] is committed to
improving patient, visitor and staff safety by reducing error and by
learning lessons from untoward/adverse incidents and accidents.
This policy describes Nottingham University Hospitals NHS Trust
approach to the management of Serious Untoward Incidents [SUIs]
and near misses, a key component of the Trust’s Risk
Management Strategy.

‘An Organisation with a Memory’ (DoH 2000), ‘Building a Safer
NHS for Patients’ (DoH 2001) and ‘Safety First’ (DoH 2006) each
emphasise the importance of learning from untoward incidents,
shared across the health community. The National Patient Safety
Agency (NPSA) shares NUH’s commitment to promoting active
learning and emphasis on a culture of open inquiry rather than
blame.

The goal of incident management is to reduce the likelihood of
recurrence, manage risks effectively, improve patient care and
deliver safe quality services. The Trust seeks to establish an
environment where the whole organisation learns from safety
incidents, where the investigation process is fair, equitable and
focused on learning and change.


2. POLICY STATEMENT AND AIMS

Nottingham University Hospitals NHS Trust is committed to the
prediction, prevention and control of risk as a tool to improve the
quality of patient experience and outcome as described in the NUH
Risk Management Strategy.

The recognition and management of, and learning from, untoward
incidents are a crucial element of the NUH Risk Management
Strategy. Open, accurate, and timely reporting allows the Trust to
put things right for the people affected, learn lessons and change
its systems to prevent recurrence, and informs our priorities for
training and investment.

The Trust actively promotes an open but accountable culture,
which enables staff to raise concerns around safety issues without
fear of blame or retribution through participation in incident
reporting. The Trust Board appreciates that completion of an

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incident report form may cause fear of disciplinary action, and that
this may deter staff from reporting incidents.

Completion of an incident report form is not considered an
admission of liability. Staff who make a prompt and honest report
will be treated fairly and supported. Disciplinary action will only be
considered as part of the response to an incident in specific
circumstances, where there is clear evidence of gross professional
misconduct, the same individual being involved in a number of
incidents, deliberate failure to report an incident or to co-operate
with an investigation.

NUH seeks to exceed all national policies and guidance for
openness and the provision of information for patients and their
carers [Refer to NUH Being Open Policy].

This policy supports NUH’s statutory duty to report Serious
Untoward Incidents.

NUH recognises the importance of support and timely information
for patients, relatives and staff involved in incidents [Refer to NUH
Being Open Policy].

The comprehensive management of incidents allows prompt
action to be taken to minimise the effects of the incident, reduce
risk and improve the safety of patients, staff and visitors. A
proactive approach to safety enhances our reputation and public
confidence.

Accurate and timely reporting of all incidents and near misses
enables the organisation to identify themes and trends, which
provide information to inform education and training programmes,
revise policies, procedures and guidelines to enhance safety, and
ultimately build on our strengths and improve areas of weakness. It
informs the Trust of systems failures for which remedial action is
necessary to reduce the likelihood of recurrence and allows NUH
to share information across the Health Service, for example via the
National Patient Safety Agency [NPSA], and influence change at a
national level.

Incident management can help ensure that resources are targeted
effectively when implementing solutions and can provide an early
warning of potential complaint or litigation.


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Finally, a robust approach to incident management, demonstrates
compliance with external accreditation standards, for example the
NHSLA Risk Management Standards and the Healthcare
Commission’s Standards for Better Health, and ensures that the
Trust meets its legal obligations.


3. SCOPE

This Policy describes the management of serious untoward
incidents, clinical and non-clinical. It outlines the procedures and
responsibilities of all staff for reporting, investigating and learning
lessons from SUIs.

The policy applies to all staff employed within the Trust (permanent
or temporary or honorary), students and volunteers, contractors
and employees of other organisations working on the Trust’s
estate.

The policy applies to incidents in NUH premises, or in other
premises where services are provided by NUH, or which occur as
a direct consequence of NUH care.

The Trust also recognises its responsibility to external regulatory
and monitoring agencies, including:

        Commissioner – Lead PCT
        NHS East Midlands (SHA)
        The National Patient Safety Agency [NPSA]
        The Health & Safety Executive [HSE]
        The Medicines and Healthcare Products Regulatory Agency
         [MHRA]
        The Serious Hazards of Transfusion scheme [S.H.O.T]
        The Healthcare Commission [HC]
        Counter Fraud and Security Management Services [CFSMS]
        NHS Estates [NHSE]
        The Coroner
        The NHS Litigation Authority


4. DEFINITIONS

Several factors influence the degree of investigation required after
an incident or near miss: the seriousness of the event, including
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the degree of harm suffered, impact on service delivery, reputation
of the Trust, the likelihood of recurrence, the potential for learning
and changing practice, and the frequency of events (even when no
or little harm is caused).

A Serious Untoward Incident is an event or accident in which:

      A patient, member of staff or member of the public suffers (or
       is exposed to the risk of) serious injury, major permanent
       harm, or unexpected death or
      Actions of NUH staff are likely to cause significant public
       concern or
      There might be serious impact upon the delivery of services
       and/or media attention and/or litigation and/or a serious
       breach of service standard or quality.

The NHS East Midlands provided an extensive list of examples,
which is shown in Appendix 1. This list is not exhaustive. Advice
should be sought from the Governance Department where there is
any doubt – for contact numbers refer to Appendix 2.

‘Near miss’ serious incidents should be reported in the same way
as actual incidents.

Incidents or near misses that are not ‘serious’ should be managed
as described in the NUH Policy for the Management of Incidents,
including Near Misses.

An adverse outcome reasonably associated with NHS activity
(such as an operation) is not an SUI. Such outcomes should be
subject to Morbidity and Mortality Meeting (M&M) review.
Directorates will wish to ensure that an event recognised some
time later as an SUI (in M&M meetings or by other mechanism) is
reported as an SUI and is subjected to appropriate investigation.
Where there is doubt about whether an SUI or an incident has
occurred, advice should be sought from the Executive Business
Manager (EBM)/Head of Governance or relevant Executive
Director.




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5. ROLES AND RESPONSIBILITIES (WHAT TO DO)

5.1        All staff

            The staff member who first becomes aware of an incident
            should:

                  Ensure that immediate actions are taken to prevent
                   further harm
                  Report the events to their line manager (or senior
                   member of staff on duty) [the Responsible Manager]
                  Consider whether equipment or notes need to be
                   secured
                  Report the incident using the hospital incident reporting
                   forms (and send to the Governance Department)
                  Ensure the clinical team looking after the patient is
                   informed

            Some of the above may be too much for the person to
            undertake immediately after an incident and may have to
            be undertaken jointly with the responsible manager [see
            below, para 5.2].

            An incident may only be recognised as a Serious Untoward
            Incident some time after the event. In such cases the
            member of staff to whom such evidence comes to light
            must report the incident as described in this policy.

            Where a member of staff considers that an incident is not
            being properly addressed they should first discuss this with
            their line manger, but they have recourse to the Trust’s
            Whistleblowing Policy if their concerns are not allayed.

5.2        The Responsible Manager should:

                  Confirm that all necessary immediate actions for safety
                   have been taken.
                  Help the reporting staff member complete the actions
                   under 5.1.
                  Assess whether the event might be a SUI. If s/he
                   considers this possible s/he should inform the
                   Directorate Clinical Director or Head Matron (Clinical
                   Lead) or Head of Service or Duty Senior Manager.

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                  Ensure that staff are aware of available support via
                   their GP, Occupational Health, HR Department and
                   professional organisations and trade unions.
                  Monitor staff who may have been affected by an SUI,
                   direct them to support if appropriate, and inform the
                   appropriate Directorate Clinical Director, Directorate
                   General Manager or Head Matron (Clinical Lead) of
                   ongoing concerns.
                  Ensure that all media requests for information about
                   the incident are directed to the Communications
                   Department.
                  Encourage staff to record their recollections as soon as
                   possible and practicable after an incident / event.
                   (Such a personal record should NOT be placed in the
                   patient case notes. Staff may wish to and should be
                   advised to share such a record with their trade union or
                   professional body).

5.3      The Directorate Team - Clinical Director / Head Matron
         (Clinical Lead) / Directorate General Manager or Head of
         Service / Duty Senior Manager will:

          Report any potential SUIs immediately to the Duty
           Executive Director.
          Ensure that the patient, member of staff, or member of the
           public involved in the incident (and, where appropriate,
           relatives or next of kin) are appropriately informed as soon
           as possible. They should be informed that an incident has
           occurred, and of the likely consequences and immediate
           actions being taken.
          For patients it may be appropriate to delegate this to a
           senior member of the clinical team (where necessary the
           on-call Consultant). This discussion should be recorded in
           the medical record. For other involved persons the
           manager should keep a written record of all discussions
          Ensure that those principally involved are informed before
           any response is made to a media request (liaise with Duty
           Director).
          The Line Manager should ensure that staff are aware of
           the available support, i.e. via their GP, Occupational
           Health, HR Department and professional organisations
           and trade unions.
          Ensure that all media requests for information about the
           incident are directed to the Communications Department.
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5.4      The Duty Director

          May seek immediate advice from colleague Directors
           (notably from the Medical Director and Director of
           Nursing). For many incidents it may be agreed that
           another Director should assume responsibility for
           managing the incident and its investigation [Responsible
           Director for the SUI].

              Where the incident is not confirmed as an SUI,
              appropriate actions might include (eg) a lesser degree of
              examination (as a high level incident) or a Mortality and
              Morbidity review or a departmental review (this list is not
              exhaustive).

5.5       The Responsible Director

          Ratifies an event as an SUI, and ensures prompt
           communication with the CEO and with the EBM/Head of
           Governance (to agree notification of all relevant parties,
           including the commissioning PCT and NHS EM).
           Activation of the major incident plan, or an incident liable
           to cause significant media interest or public concern, must
           be reported to the CEO immediately and to NHS EM
           within two hours [for Major Incident management see
           NUH Major Incident Plan].
          Ensures that an SUI Inquiry does not compromise lines of
           responsibility to inform other agencies, including the
           Police [see DoH Memorandum of Understanding –
           Investigating    Patient    Safety    Incidents    involving
           unexpected death or serious harm: protocol for liaison and
           effective communications between the National Health
           Service, Association and Chief Police Officers and Health
           and Safety Executive Feb 2006].
          Ensures that where there are issues of Child or
           Vulnerable Adult welfare or protection, these are
           considered and appropriate reports made in keeping with
           the Trust’s Child Protection Policy. The Named Doctor for
           Child Protection or Trust Secretary is available to give
           advice.
          Agrees a communications strategy with the Director of
           Communications (or deputy) as soon as practicable. The


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              Responsible Director is accountable for the initial external
              and internal communication.
             Agree with the Director of Communications (or deputy)
              who will liaise re the communications strategy with the
              commissioning PCT and NHS EM.
             Specifically consider with the Director of Communications
              (or deputy) whether a ‘hotline’ should be established
             Ensures that those principally involved are informed
              before any response is made to a media request.
             Appoints an Inquiry Lead (in consultation with the Medical
              Director) who will be responsible for ensuring the incident
              is investigated in line with this policy (and associated
              procedures).
             Ensures that the Trust Board is notified at its next
              meeting.
             May, after discussion with the CEO, inform the Chairman
              and / or other non-executives at an earlier date. The
              Board notification may be in public or private session, at
              the discretion of the CEO and Chairman.
             Will consider if more than one organisation is involved in
              the SUI. The organisation that identified the incident must
              make the initial report to the commissioning PCT and
              NHS EM. Where this is NUH the Responsible Director will
              arrange a meeting that includes all key stakeholders, and
              identify an appropriate Inquiry lead to co-ordinate and
              manage the investigation. This applies also to
              Independent Sector Providers. All organisations involved
              in an Inquiry have a duty to uphold the principles of
              confidentiality enshrined in the Caldicott principles and
              relevant statutes.
             May, in exceptional circumstances, after further
              consideration, downgrade an incident from an SUI. This
              must be discussed with the CEO.

5.6      The Executive Business Manager / Head of Governance /
         Clinical Risk Lead / Risk Management Adviser

                  Ensure that within one working day that a ‘High
                   Priority’ email is sent to ALL Directors, the SUI is
                   reported to the Commissioning PCT, NHS EM and the
                   untoward incident module of STEIS is completed



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                  Ensure that any relevant previous SUIs and
                   investigations are made known to the Responsible
                   Director and Inquiry Team Lead
                  Convey to the Commissioning PCT and NHS EM (via
                   the STEIS system) the Inquiry report, within 60 working
                   days [extension of this period may be appropriate for
                   complex investigations and should be by with
                   agreement with these bodies].
                  Ensure that all Directors and the relevant Clinical
                   Director / Head Matron (Clinical Lead) / Head of
                   Service / Senior Manager, patient and relatives are
                   informed if the Responsible Director subsequently
                   decides that the event is not an SUI (and that decision
                   is ratified by the CEO)

5.7      The Medical Director

         Provides the Board with regular updates (at least quarterly)
         on the progress of SUI investigations and describes the final
         outcome of these investigations to the Board in a scheduled
         or extraordinary report (as agreed by the CEO).            Is
         responsible for the production of a quarterly ‘Lessons
         Learned’ Bulletin.

5.8      The Chief Executive

         Is accountable for the management of SUIs, but delegates
         this responsibility as described in this policy. The CEO must
         ensure that information is available so that staff know how
         and when to report an incident.

5.9       Committees

         The Clinical Risk Committee (CRC) will monitor and review
         the effectiveness of this policy and the associated
         procedures. Through its Incident Review Committee it will
         review all SUI reports and recommendations, ensure that an
         action plan to implement safety solutions is developed by the
         most appropriate people with clearly identified accountability
         for actions, and ensure that investigations and reports (or
         relevant elements of them) are appropriately anonymized
         and shared with stakeholders. The action plan will be
         regularly monitored to ensure timely closure.

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         Exceptions or deviations from the action plan(s) will be
         forwarded by CRC to the Risk Management Committee
         (RMC), which will ensure that any outstanding identified risks
         are addressed. The CRC will ratify closure of an SUI action
         plan, which will be reported to the Board.

         The CRC or RMC may wish to involve other relevant Trust
         committees in the response to an incident or SUI report. This
         is the responsibility of the Chairs of these committees to
         ensure such involvement.

         Terms of reference for both these committees are shown in
         Appendix 3.

5.10 Trust Board

         Receives regular monthly updates on the progress of all SUI
         investigations via the Medical Director and takes assurance
         from the Audit and Risk Management Committees that action
         plans are being implemented and monitored.


6.     INTERNAL INQUIRY AND REPORT

6.1 Serious Untoward Incident Inquiry Team (SIT)

       Each SUI will be subject to comprehensive investigation. This
       will follow NPSA guidelines, and include Root Cause Analysis
       [RCA] unless agreed by the Responsible Director.

       Actions or omissions by staff members preceding an incident
       are frequently evident, but these are often difficult to eradicate
       because they frequently involve attention failures or memory
       lapses. Closer analysis of the incident (RCA) may reveal a
       series of events and organisational or process issues in the
       period of care leading up to the adverse outcome. The
       action(s) of the individual member of staff may act as a trigger
       against the backdrop of these organisational shortcomings.
       The aim of an SUI investigation is to identify such
       shortcomings. RCA provides a consistent investigative
       approach that seeks to describe all the causal factor[s] of an
       incident, which enables the development of comprehensive
       solutions to reduce or eliminate the risks.
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       Training will be provided in the tools and techniques of RCA
       for key groups of staff.

       It may be appropriate to use the SUI investigation process for
       the investigation of complaints. When an SUI Inquiry is being
       undertaken, any complaint will be made available to the
       Inquiry team. Only where the Inquiry team remit does not
       include all the elements of the complaint should a separate
       complaints investigation be undertaken (though the Inquiry
       Lead must ensure that the complaints department receives
       timely progress reports).

       Membership of the SUI Inquiry Team (SIT) is agreed by the
       Responsible Director. The Inquiry Team Lead is responsible
       for the conduct of the investigation.

       A SIT will usually comprise at least three persons who must
       not have been directly involved in the incident. They should
       include an appropriate senior clinician, a senior clinician who
       has clinical expertise that is relevant to the incident, and at
       least one senior manager or member of the Governance team.

       This policy is not prescriptive about the required organisational
       level for SIT Lead or member. However where the incident has
       had catastrophic impact (or might have had if a near miss) the
       Chair will be a Trust Director.

       In certain incidents it may be appropriate to investigate an
       incident in partnership with another stakeholder (e.g. PCT or
       NPSA), or by appointment of an independent person or panel.
       The CEO must ratify any such joint inquiry team (and its
       membership) or external involvement.

       The terms of reference (ToR) for a SIT are agreed by the
       Inquiry Lead and the Responsible Director. The SIT will have
       the CEO’s authority to make all necessary enquiries of any
       staff (at the SIT Lead’s discretion) in order that all possible
       lessons can be learned from the incident and
       recommendations made to prevent recurrence and improve
       patient and staff safety. The SIT Lead can at any time seek
       from the Responsible Director a change in the ToR if s/he
       feels that is appropriate or necessary and in keeping with the
       principles and aims of this policy.
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       In establishing an SUI Inquiry Team the Responsible Director
       or Inquiry Team Lead (through the Responsible Director) may
       wish to seek advice from the EBM or via the EBM from the
       Trust Secretariat or Legal Advisors. The Inquiry Team Lead
       has access to such advice and to specialist HR advice (from
       the Director of HR) during the conduct of the investigation.

       For the majority of infection control SUIs the Responsible
       Director in conjunction with the Medical Director (in his role as
       Director of Infection Prevention and Control) may agree that
       the relevant clinical team will assume the role of the SIT.

6.2 Conduct of the Inquiry

       The Inquiry is not part of the disciplinary process. The SIT
       however has a responsibility to examine and comment on the
       discharge of professional duties and accountability by those
       involved in the incident and to make recommendations. Only
       where there are significant breaches of expected standards
       and/or significant non-adherence to Trust policies and
       procedures will staff be subject to disciplinary proceedings.
       Staff should be reassured that the investigation’s primary aim
       is not to establish blame, but to understand the organisational
       context within which the incident occurred (what went wrong,
       not who did wrong).

       Staff are encouraged to be open and frank with the Inquiry
       team, and the team should ensure that it has discussion with
       staff without fear of blame or retribution. Staff should be
       encouraged to record their recollections as soon as possible
       after an incident / event. Such a personal record should NOT
       be placed in the patient case notes. Staff may wish to and
       should be advised to share such a record with their trade
       union or professional body.

       A guide to the Inquiry process, including advice on support,
       writing accounts for the Inquiry, and what to expect if the
       Inquiry team interview you, is contained in Appendix 4.

       The SIT should always consider involving the patient
       concerned and (with patient consent if appropriate) their
       relatives, in order to identify any specific concerns they may
       have and, by explanation, give them confidence in the
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       thoroughness of the investigation process. Patients should be
       offered the opportunity to talk to the team and/or offer a written
       submission.

       All NUH staff involved in an incident must work to support
       patients and relatives. This will involve explanation of the
       investigative process and referral to the Patient Advice and
       Liaison Service [PALS]. It will usually be appropriate for the
       clinical team involved to discuss events with the patient’s GP.
       This discussion should be recorded in the patient’s case
       record.

       Staff involved in an incident will require support. The Line
       Manager should ensure that staff are aware of available
       support via their GP, Occupational Health, HR Department
       and professional organisations and trade unions. Some may
       need an identified mentor to support them through the
       process. The SIT Lead is responsible for keeping involved
       staff informed of the progress of investigations.       The
       Governance Department provide an additional source of
       information and advice.

       To obtain the best results from its Inquiry the SIT should apply
       RCA methodology (unless agreed by the Responsible
       Director). Events should be considered in the following
       domains

        Organisational and management factors
        Work Environment (e.g. staff levels, skill mix and work
         patterns)
        Team factors (e.g. communication and supervision)
        Individual staff factors (e.g. knowledge, skills)
        Task factors (e.g. availability of protocols / tests / results)
        Patient characteristics (e.g. complexity and seriousness)

6.3      Inquiry Report : Format

         The SIT Report should follow a standardised format,
         described in Appendix 5.




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6.4      Sharing the Report and Lessons Learned
         [see also Section 10]

         The Report should initially be presented to the Responsible
         Director, who may seek further work, clarification or suggest
         amendment. The ‘final’ version is the responsibility of the SIT
         Lead, who is responsible for version control.

         The Responsible Director, advised by the EBM, should agree
         with the SIT Lead distribution lists for SIT reports and their
         timing. There should be the widest appropriate distribution of
         an anonymised report. Patient and staff confidentiality must
         be preserved and should be considered in every draft of the
         report. Care should be taken to ensure that patient and staff
         personal details (see paragraph 6.5) are not included in
         general distribution of the SIT report.

         If legal proceedings are coincident with the Inquiry, the Lead
         should seek advice from the EBM or Trust Secretary on the
         report’s distribution.

         The SIT Lead may wish staff involved to have sight of
         relevant extracts of the report before its general distribution
         (to seek their confirmation on matters of accuracy). The SIT
         Lead has discretion to waive this process if this is agreed
         with the Responsible Director. The exercise of this discretion
         should be noted in the report. The SIT report disclosed to
         staff should have all patient and staff personal data removed
         in accordance with paragraph 10. Staff may wish to and
         should be advised to seek the advice of their Trade Union or
         Professional Organisation.

         The final draft version should be distributed to each member
         of the CRC and RMC. The Report will be considered by the
         CRC and ratified by the RMC, before being described to the
         Board by the Medical Director in a scheduled or
         extraordinary report (as agreed by the CEO).

         Patients and relatives should have sight of the SIT report
         (patient and staff personal data having been removed in
         accordance with Section 10) before its general distribution,
         and their comments sought on matters of accuracy, on
         whether the report addresses their concerns, and on their
         response to the recommendations. The SIT Lead should
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         always offer to meet patients and/or relatives if they so wish.
         Where such a meeting has not taken place this should be
         described in the final report. The Trust may wish to offer a
         further meeting with Trust Officers after formal consideration
         of the report.

         The SIT Lead will consider with colleagues whether a formal
         staff meeting to consider the Report (‘debriefing’) is required.

         Clinical Directors should identify forums through which the
         lessons learned in investigation and SIT recommendations
         can be disseminated through their directorate. The
         effectiveness of these mechanisms will be monitored by
         CRC.

         The Medical Director will be responsible for a quarterly
         LESSONS LEARNED BULLETIN, which will be distributed to
         all ward and departmental managers (via the hospital
         intranet). This will include synopses of all SIT Reports and
         Recommendations, suitably anonymised in accordance with
         Section 10.

         The Report may include recommendations that it be
         forwarded to relevant professional bodies, notably the
         General Medical Council [GMC] and the Nursing and
         Midwifery Council [NMC]. The Responsible Director may also
         recommend such a course. The final decision regarding such
         onward transmission rests with the NUH Board.

         General distribution should only be made in accordance with
         Section 10.

6.5      Action Plans and Monitoring

         Each relevant Directorate (as agreed by the SIT Chair and
         Responsible Director) should generate an Action Plan to
         address SIT recommendations. There is a standard format
         for this action plan, available from the Governance Team.

         The plan should have clear timescales and describe named
         individual responsibilities.




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         The plan should include a one-year review of each of the
         recommendations and (where appropriate an audit of the
         actions).

         The robustness of the Action Plan and its implementation
         (including the one-year audit) will be monitored by the CRC.


7        ANALYSIS OF SUI THEMES AND TRENDS

Corporate risk leads will interrogate the Datix system to identify
themes and trends. The Incident Review Committee and
subsequently Clinical Risk Committee and Trust Board will receive
regular reports.

Directorates and specialties have a responsibility to review all
incidents associated with their services, to take action and provide
feedback through their local forums.

Directorates, Corporate Functions and Committees will work in
collaboration with the Incident Review Committee to review
themes, trends and action plans and to share lessons.


8        MONITORING

The effectiveness of this policy will be routinely monitored through:

     Feedback of incident statistics and analysis to Managers and
      Committee leads
     Reports to the Risk Management Committee and
      subsequently to all other appropriate Trust Committees
     Trust-wide Audit.
     Reviews of investigations and follow-up action taken by local
      managers/governance forums.
     Reports on progress against the Clinical Governance
      Development Plan.
     Trust-level assurance to the Board through the Risk
      Management Committee and a monthly SUI register and
      report.




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9        TRAINING

To ensure that staff are aware of the importance of reporting and
managing incidents and near misses training will be provided
through:

      Corporate induction programmes
      Local induction packages
      Ongoing governance education

Managers are required to promote staff involvement and
attendance. Training and advice is available through the
Governance Department on all aspects of this Policy and
Procedures and on ‘writing an account of events’ (statements),
conducting and attending interviews, and Root Cause Analysis.

The principles described in the policy accord with the Trust’s Risk
Management Strategy, to which staff are introduced at induction.


10       RECORDS MANAGEMENT and CONFIDENTIALITY

10.1 Document Storage and Disposal

         Incident report forms are sensitive documents, should be
         considered confidential, and must be stored securely. The
         Trust has a legal obligation to retain incident forms for a
         period of 10 years. This is done centrally. Additional copies
         should be disposed as confidential waste once
         investigations and actions are complete.

         Incident forms are not part of a patient’s healthcare record
         and must not be filed in patient notes. It is however usually
         appropriate to record that there has been an adverse event
         in the body of the record – this is mandatory for clinical
         untoward events.

         Incident forms can however become the subject of internal
         and/or external scrutiny and must be completed to the same
         standards of accuracy with objective, factual description as
         expected in the clinical record.


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10.2 Disclosure of SUI Information and Reports (FOI)

         The Trust seeks to promote a culture of openness, which is a
         pre requisite for improving patient safety and the quality of
         healthcare systems.

         The Trust works to ensure compliance with all national
         policies and guidance on ‘being open’, and to provide
         information for patients and their carers in an open and non-
         defensive manner (see Being Open Policy).

         It is important to inform the person involved in the incident
         and, where appropriate, their next of kin as soon as
         practically possible, and to record this on the incident report
         form. Where a decision is taken not to inform the patient or
         next of kin, the reasons for this should also be clearly
         documented on the form AND in the body of the healthcare
         record.

         Any written information produced as part of the NUH SUI
         reporting process will be potentially disclosable under the
         Freedom of Information Act 2000 (“FOIA”), unless an
         exemption applies to the information. Given the nature of
         SUIs, any documents produced are likely to contain personal
         data or sensitive personal data belonging to patients,
         members of the public and/or staff. This information is
         protected under the Data Protection Act 1998 (“DPA”), and
         NUH is under an obligation to ensure that it is processed
         only in accordance with the data protection principles
         enshrined in the DPA. Personal information is defined as
         being information relating to a living individual who can be
         identified from that information. It must be biographical in
         nature. Personal data will be classed as sensitive personal
         data if it relates to racial/ethnic origin, political opinions, trade
         union membership, physical or mental health, sexual life, the
         commission or alleged commission of an offence or
         proceedings relating to an offence.

         When a request for SUI information is received from a third
         party, section 40 of the FOIA will be relevant. Information
         should not be disclosed if it would lead to personal
         information relating to patients, members of the public and/or
         staff (excluding details of staff acting in their official capacity)

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         being disclosed in breach of the DPA and those individuals
         being identified.

         Care must be taken when disclosing any SUI information,
         and thought must be given to how information held by NUH
         may be used in conjunction with other readily available
         information to identify individuals involved.

         Section 31 of FOIA will be relevant if a request for
         information is received during the SUI investigation process,
         but only to the extent that disclosure would prejudice the
         investigation. The Trust Secretary or Trust Solicitors should
         be consulted before any decision is made. Evidence of a
         significant risk of harm is required. The public interest test
         will also need to be applied before a decision as to
         disclosure is made.

         In addition, section 36 of FOIA may also be relevant if
         disclosure of information would or could prejudice the
         effective conduct of public affairs. This may be a risk if, for
         example, disclosure would inhibit the free and frank provision
         of advice or exchange of views by effecting the willingness of
         staff to come forward and report SUIs because of the fear of
         blame, or if disclosure would prejudice NUH’s ability to offer
         an effective public service, or to meet its wider objectives,
         due to the disruption caused by the disclosure and the
         diversion of resources in managing the impact of disclosure.
         The decision on whether section 36 is applicable can only be
         made by the CEO. The public interest test will also need to
         be applied.

         As a guide, personal statements of staff should not be
         disclosed. Individual SIT reports should not normally be
         disclosed unless (1) you have consulted with the EBM, Trust
         Secretary or Trust Solicitors, and (2) the reports are
         anomymised and (3) you are confident that no individuals
         can be identified from the report or in conjunction with other
         information available elsewhere.            Lists of SUIs,
         recommendations, changes in practice, Lessons Learned
         Bulletins and statistical data should normally be disclosed
         but limited to describing the broad nature of the incidents,
         and no information should be included which could lead to
         the identification of the individuals involved. Date and
         location of the incident should be carefully considered in
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         case this information makes it possible to identify individuals.
         It may also be advisable to put the data into context and
         emphasise the open reporting and learning aspects of SUI
         reporting. This should not be taken as a definitive rule, and
         each request for information should be decided on its own
         merits. The Trust Secretary or EBM should be consulted
         before any disclosures are made.


11       EQUALITY AND DIVERSITY STATEMENT

NUH is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way
we treat our staff reflects their individual needs and does not
discriminate against individuals or groups on the basis of their
ethnic origin, physical or mental abilities, gender, age, religious
beliefs or sexual orientation.


12       SUPPORTING POLICIES AND PROCEDURES

          Risk Management Strategy [October 2006]
          Policy for the Management of Incidents, including Near
           Misses [November 2007]
          Being Open Policy [NUH policy under development]
          Whistleblowing Policy [August 2006]
          Major Incident Plan [May 2006]
          DoH Memorandum of Understanding – Investigating
           Patient Safety Incidents involving unexpected death or
           serious harm: protocol for liaison and effective
           communications between the National Health Service,
           Association and Chief Police Officers and Health and
           Safety Executive [Feb 2006]
          Infection Control Policy and Procedures [May 2007]
          Safeguarding Children and Vulnerable Adults Policy [NUH
           policy under development]
          Hotlines Policy [NUH policy under development]
          Mental Capacity Act 2005 Policy [September 2007]
          Standards of Business Conduct Policy [April 2006]
          Coroner’s Inquest Policy [May 2006]
          Claims Handling Policy [July 2006]
          Fire Policy Manual [August 2006]
          Fraud and Corruption Policy [April 2006]
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          Grievance Policy [April 2006]
          Disputes Policy [June 2006]
          Management of Attendance and Sickness Policy [July
           2006]
          Disciplinary Policy and Procedure [July 2006]


13       REFERENCES

          An Organisation with a Memory, (DoH 2000)
          Building a Safer NHS for Patients, (DoH 2001)
          Safety First (DoH 2006)
          Seven Steps to Patient Safety – The full reference guide
           second print, (NPSA, 2004).
          Six Steps to Root Cause Analysis, Maria Dineen,
           (Consequence, 2002).
          Doing Less Harm, (DoH and NPSA 2001)
          Effective Management of Clinical Incidents, Penny Smith,
           (NHSLA Review, 26:2003)
          Root Cause Analysis: simplified tools and techniques,
           (Bjorn Anderson and Tom Fagerhaug, 2000).
          Management of Health and Safety at Work Regulations,
           (Health and Safety Commission, 1999)
          Five Steps to Risk Assessment, (Health and Safety
           Executive, 1994).
          Reporting of Injuries, Diseases and Dangerous
           Occurrence Regulations, (Health and Safety Executive,
           1996).
          Risk Management in the NHS, (NHS Executive, 1994).
          Health and Safety at Work Act, (Secretary of State for
           Employment, 1974).
          NHSLA Risk Management Standards (April 2007)




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                                                                  Appendix 1

    CRITERIA FOR REPORTING AN SUI TO COMMISSIONING
                 LEAD PCTs AND NHS EM

The following are criteria for reporting Serious Untoward Incidents.
It is not an exhaustive list and is intended as a guide only. Where
there are any doubts about an incident it should be reported
following the procedure outlined in Section 5.

Major Incidents

Any circumstance which necessitates the activation of the Trust’s
major incident plan.

Incidents involving harm to Patients / Service Users

     Clusters of unexpected or unexplained deaths (report before
      investigation is undertaken to clarify suspicions)
     Maternal deaths (due directly or indirectly to pregnancy or
      child birth)
     Death or injury where foul play is suspected.
     Serious event including unexpected death, injury or errors
      involving patients e.g. wrong site surgery, medication errors,
      failures in diagnosis resulting in significant morbidity or
      mortality.
     Death in custody
     The suicide or suspected suicide of any persons currently in
      receipt of NHS services, on or off NHS premises, this
      includes
     Patients currently in receipt of mental Health services, or
      who have been discharged within the last twelve months
     Patients of primary care providers.
     Where there is obvious evidence or strong suspicion of self
      harm or
     Where the above does not apply initially but emerges later
      from a clinical review of the case, or discussion at the
      incident monitoring group, or
     Where the Coroner’s verdict is suicide (or open verdict)
     Serious incidents that result in death, significant injury or
      abuse to children where reported under child protection


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      arrangements or an adverse event which results in a serious
      case review (Part 8)
     Significant harm to adults where reported under vulnerable
      adult arrangements.

Incidents involving Staff and Others

     Serious injury or unexpected death involving a member of
      staff, visitor, contractor or another person to whom the
      organisation owes a duty of care.
     All incidents where suspension from duty is contemplated
      and there is likely to be public interest or the incident is of a
      serious nature as define within this list:
     Serious complaints about a member of staff or primary care
      contractor
     Suspicion of a serious error or errors by a member of staff or
      primary care contractor
     A serious drug error resulting in harm to a patient.
     A serious breach of confidentiality.
     Serious verbal and/or physical aggression.
     Requests for the issuing of an alert letter.
     Problems that may have a serious impact on public health or
      there is a perceived threat to the health of individual patients.
     Significant threat to public safety.
     If referral to the relevant regulatory body is contemplated.
     Suggestions of significant inappropriate conduct, sexual or
      otherwise.
     Definite criminal activity or involvement of the police.
     Significant inappropriate use of or prescription of controlled
      drugs.
     Strong likelihood of stories reaching the media.
     Individual incidents or clusters of incidents, which result in a
      midwife being put onto supervised practice.
     Suspected fraud
     Suspicions of high levels of mortality.

Healthcare Associated Infection / Infection Control

     All identified cases of MRSA bacteraemia
     Specific cases of Clostridium Difficile (An outbreak of
      C.difficile and serious /fatal cases of C.difficile where there


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         was a clear breach of prevention or treatment of C.difficile
         policies/guidelines.
        Incidents that result in significant morbidity or mortality.
        Involve highly virulent and transmissible organisms.
        Require control measures that have an impact on the care of
         other patients, including limitation of access to healthcare
         services.
        All community based outbreaks.
        Outbreaks that are sufficiently serious to require the
         convening of an incident team
        Transmissible with an impact on staff, patients or the
         community.
        Infected healthcare worker or patient incidents necessitating
         consideration of look back investigations (e.g. TB, vCJD,
         blood borne infections)
        Significant breakdown of infection control procedures with
         actual or potential for cross-infection (e.g. release of
         products from a failed sterilisation cycle, contaminated blood
         transfusion)

N.B. These incidents should also be reported to the health
Protection Agency.

Mental Health Incidents

     The disappearance, absence without leave or absconsion of
      a service user (whether or not detained under the Mental
      Health Act 1983) where there is serious cause for concern.
     Homicide, or suspected homicide, by any service user who
      has received care provided by specialist mental health
      services, that is has been under the care programme
      approach (CPA).
     Escapes by patients (whether or not detained under the
      Mental Health Act 1993) from secure accommodation

Forensic Mental Health Incidents

     Incidents occurring within high secure services (Rampton
      Hospital), have additional reporting criteria documented
      within the Forensics Untoward Incident Reporting Policy and
      are managed by the Forensics Lead at NHS EM.
     Premises / Equipment Incidents
     Failure of equipment which could endanger life.
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     Serious damage to NHS or primary care premises or
      property e.g. through fire, flood or criminal activity which
      results in serious disruption to services.
     Suspicion of malicious activity e.g. tampering with
      equipment.
     Circumstances that lead to the provider no longer being able
      to provide an element of the service.

Medico – Legal Incidents

     Suspicion of large-scale theft or fraud, which might give rise
      to serious criminal charges or major litigation.
     Impending court hearing or out of court SITtlement in cases
      of large-scale litigation (including negligence claims).

Incidents relating to Home Oxygen Service

     Any incident that involves the death of a patient where the
      integrity of the home oxygen service is challenged.
     Any serious failure of service delivery, including
      compromised supply of oxygen.
     Delayed discharge from hospital or inappropriate emergency
      readmission
     Health and safety incidents relating to the use of oxygen
      equipment including fire.
     An incident where the quality of healthcare has been
      significantly compromised – this may include severe distress
      to service users and their carers

Other significant untoward incidents, including:

     Apparently trivial events, or clusters of events, which lead to
      something more significant, including those which could
      attract media attention
     Any deviation from the Retained Organs Commission
      Guidance.

Actual or potential public health hazards [report to EPA and EM
NHS Director of Public Health].

Death or serious injury from suspected or actual Non-accidental
injury of a child or vulnerable adult (local child protection
procedures must be followed and the area child protections

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committee must be informed). [Report to a designated Child
Protection Doctor who will advise].

Referral of a member of staff to the Protection of Children Act 1999
List [report to NHS EM]

An incident reported to National Confidential Inquiry [reported to
NHS EM]




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                                                                  Appendix 2


                GOVERNANCE TEAM CONTACT NUMBERS




Medical Director                            Via PA
                                            NCH campus Ext. 56919
                                            QMC campus Ext. 62235


Executive Business Manager,                 Ext. 61714
Head of Governance


Clinical Risk Lead                          Ext. 63858


Risk Management Adviser                     Ext. 62553


Governance Facilitators                     Ext. 57447


Trust Secretary                             Ext. 62349


Claims Manager                              Ext. 68474




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                                                                        Appendix 3a

                                       TERMS OF REFERENCE
                                   RISK MANAGEMENT COMMITTEE


Membership

Chief Executive’s Team
Clinical Directors

Pre-nominated deputies may attend in the absence of a
substantive committee member.

In attendance

Trust officers with lead responsibilities concerning risk to be in
attendance, as and when required

Chairman

The Chief Executive shall chair the meeting. In their absence, the
Medical Director shall chair.

Quorum

No business shall be conducted unless the Risk Management
Committee is quorate. The quorum is seven members, provided
that this includes at least one of the following (one of whom shall
act as chair):

     Chair
     Medical Director
     Director of Nursing

Frequency

The Committee shall hold monthly meetings (currently the first
Tuesday of the month).

Reporting

Reports to the Directors’ Group.

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The Committee (via the Chief Executive and/or Medical Director)
shall also maintain a reporting relationship to the Audit Committee
and the Trust Board, as and when appropriate.

Role and Objectives

     Determine the Trust’s strategy for risk management

     Oversee and co-ordinate the process of risk management,
      and monitor actions to mitigate risks

Duties

 Oversee the delivery of the Trust’s Risk Management Strategy.

 Ensure that policies and procedures for risk management and
  incident reporting are maintained and well-communicated, and
  that managers and staff are appropriately trained and supported
  in their use

 Identify significant risks to the Trust and manage the Risk
  Register (including population by Divisions and Corporate
  Departments and actions identified against significant risks)

 Agree, disseminate and manage key performance indicators in
  risk management and incident reporting (including the use of IT)

 Agree the Trust’s Annual Risk Report

 To receive reports from, and provide instruction and decisions
  to, Clinical Divisions, Corporate Departments, its own
  committees and other groups, as appropriate.

 Contribute to, and approve, the Trust’s Annual Governance
  Plan

 To receive and review all Internal Audit reports

 Monitor compliance against the Trust’s Assurance Framework,
  Annual Health Check (Standards for Better Health), clinical and
  non clinical insurance scheme assessments, statutory
  requirements, relevant national guidance, and similar standards
  and agree necessary returns / reports

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Committees

The Risk Management Committee shall determine whether it may
be assisted in discharging its responsibilities by the appointment of
one or more committees to address specific issues within risk
management. Such committees shall report, and be accountable,
to the Risk Management Committee.

Date of Next Review

March 2007 (currently under review)



08/05/06




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                                                                      Appendix 3b

                                    TERMS OF REFERENCE
                                   CLINICAL RISK COMMITTEE

Aim

To minimise the risks of adverse events to patients and staff
associated with clinical services provided by NUH staff.

Tasks

1.   Provide leadership to the processes by which NUH predicts,
     prevents and manages clinical risks.

2.   Encourage and foster greater awareness of clinical risk
     management throughout the organisation through training and
     education.

3.   Ensure that clinical risk management becomes an integral part
     of the routine operational and business functions of NUH.

4.   Ensure that the ‘Standards for Better Health’, NHSLA and other
     Statutory requirements relevant to the Committee’s remit are
     being performance managed, and provide any additional
     monitoring for areas of low compliance.

5.   Monitor the process for prediction, identification and
     management of clinical risks through the Trust’s risk
     management processes, including the registration of
     appropriate clinical risks on the Risk Register.

6.   Define key indicators, which will demonstrate continuous
     improvement in clinical risk management activities and control
     of clinical risk.

7.   Ensure that all Policies, procedures, protocols and guidance
     relating to the remit of the Committee are monitored and
     reviewed in accordance with agreed timescales.

8.   Receive actions from other Committees where the work is
     relevant to the remit of the Clinical Risk Committee.


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9.    Review the findings of other significant assurance functions,
      internal and external, which fall within the scope and remit of
      the Committee, and identify and implement remedial action and
      performance reporting mechanisms where appropriate.

10.   Receive reports of specific Divisional risk issues from Divisional
      Governance Groups.

11.   Receive routine reports and analysis on Incidents, Claims and
      Complaints which are relevant to the remit of the Committee.

12.    Agree the Terms of Reference and annual work plans for, and
      receive regular reports from, the following Sub-committees;

         Safeguarding Children and Vulnerable Adults
         Infection Control (including decontamination)
         Medical Devices and Equipment
         Resuscitation
         Thrombosis
         NHSLA Standards (incorporating CNST)
         Incident Reporting
         Medicines Management
         Research and Development
         Transfusion
         Falls

13.   Provide input and comment on the wording and content of the
      Assurance Statement (SIC) relating to Clinical Risk
      Management for inclusion within the Annual Report.

14.   Ensure that mechanisms are in place for the ongoing
      consultation, communication and involvement of relevant
      stakeholders in clinical risk management.

15.   Recommend to the Risk Management Committee areas of
      activity for review by internal audit.

16.    Review the Committee’s Terms of Reference on an annual
      basis and if necessary make recommendations for amendment
      to RMC.




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Reporting

The Clinical Risk Committee reports to the Risk Management
Committee. A summary of key discussion points will be provided
each month to its co-subcommittees of the Risk Management
Committee, including the Clinical Effectiveness and Organisational
Risk Committees.

The Chair of the Committee shall draw to the attention of the Risk
Management Committee, and thereby to the Directors’ Group, any
issues that the Committee considers may require disclosure to the
full Board or executive action.

The Committee will report to the Risk Management Committee on
its work in support of the Statement on Internal Control, specifically
commenting on the integration of risk management and clinical
governance arrangements within the organisation. The committee
will also provide assurance to the Risk Management Committee
against the NHSLA standards and the relevant Core and
Developmental standards within Standards for Better Health.

Membership

Medical Director (Chair)
Director of Nursing or Deputy
Lead for Patient Safety
Patient Representative
Chairs of the following committees:

         Safeguarding Children and Vulnerable Adults
         Infection Control
         Medical Devices and Equipment
         Resuscitation
         Thrombosis
         NHSLA Standards (incorporating CNST)
         Incident Reporting
         Medicines Management
         Research and Development
         Transfusion
         Falls
         Estates and Facilities representation when necessary

Nominated deputies may attend on behalf of the persons named
above.
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Chair

The Medical Director shall chair the meeting. In their absence, the
Lead for Patient Safety will chair.

Quorum

No business shall be conducted unless the Clinical Risk
Committee is quorate. The quorum is seven members, provided
that this includes;

     At least one of the following, the Chair or Lead for Patient
      Safety
     Four Chairs from the relevant committees

Standing Invitation

Representatives of other risk management related committees
and/or directorates may also be invited to attend, as required.

Frequency

Meetings shall be held monthly.

The Medical Director may request additional meetings if
necessary.

Date of Next Review

August 2007 (currently under review)

Date of Approval by the Risk Management Committee

August 2006




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                                                                  Appendix 4

                      A GUIDE TO THE INQUIRY PROCESS


1.       The Chief Executive or the Responsible Director decides
         when an internal inquiry is necessary, usually following the
         declaration of a Serious Untoward Incident

2.       The Trust is obliged to externally report all serious untoward
         incidents to the Commissioning Lead PCT and NHS East
         Midlands and the patient’s general practitioner

3.       The EBM, Head of Governance is the Trust’s nominated lead
         for co-ordinating the investigation of Serious Untoward
         Incidents although in practice this role is shared with the
         Clinical Risk Lead

4.       The Chief Executive or the Responsible Director appoints an
         Inquiry Team (SIT) and sets the terms of reference for the
         inquiry

5.       The Line Manager ensures that all staff involved in an inquiry
         have appropriate support throughout the inquiry process

6.       Managers are expected to take any immediate action and/or
         implement obvious changes as a result of an incident in
         advance of the inquiry’s recommendations.

7.       The first step in the inquiry process is for the SIT to review all
         the necessary documentation, eg. the health record, policies,
         procedures and produce a chronology of events

8.       Statements from the personnel involved in the incident are
         requested, this is usually staff but may include patients and
         their relatives, visitors or contractors. Statement writing
         guidance is available from any member of the Governance
         Team. Staff may wish to and should be advised to seek the
         advice of their Trade Union or Professional Organisation on
         their statement before submitting it to the Inquiry Team.

9.       In patient related incidents the inquiry team may invite the
         patient and/or their relatives to meet with them to ensure all
         their concerns are taken account of in the inquiry.

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10.      The next step is to interview all the personnel deemed
         necessary by the SIT. This helps to increase the quantity
         and quality of information obtained from the statements.
         Questions will typically include:

               What do you think happened?
               Take us through the key stages of the incident
               Can you describe the working conditions at the time,
                for example, patient dependency/staffing levels?

11.      It may be necessary after the first round of interviews to
         arrange to see other personnel or to make reference to
         additional documentation, for example, audit reports, risk
         assessments, equipment maintenance logs.

12.      The SIT may also seek advice from an external specialist

13.      A draft report will then be prepared and everyone involved in
         the inquiry will usually be given the opportunity to comment
         on relevant extracts from the report and preliminary
         conclusions.

14.      The SIT will then consider any written comments or make
         itself available to individuals if they wish to meet with them to
         discuss the draft report and preliminary conclusions in more
         detail.

15.      The SIT’s report will then be finalised and submitted to the
         Clinical Risk Committee for approval prior to submission to
         the Risk Management Committee.

16.      Once approved by the Risk Management Committee, a full
         copy of the report, appropriately anonymized, will be sent to
         everyone involved in the inquiry.

17.      An action plan will then be drawn up from the
         recommendations and implemented within an agreed
         timetable. This will include a section on how the Trust and
         possibly the wider NHS can learn lessons from the incident

18.      The Risk Management Committee is responsible for
         ensuring that the action plan is fully implemented and will

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         periodically report to the Board on progress via the Medical
         Director.

19.      Members of the Governance Team are available for advice
         and support at any time during the inquiry process, see
         Appendix 2 for contact numbers.




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                                                                  Appendix 5



                    SUI REPORT FORMAT AND GUIDANCE



   This appendix is currently being prepared. In the interim please
       contact a member of the Governance Team for advice.




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                                                                  Appendix 6


        EMPLOYEE RECORD OF HAVING READ THE POLICY


Title of Policy/Procedure:

SERIOUS UNTOWARD INCIDENT POLICY AND PROCEDURES

I have read and understand the principles contained in the named
policy.


    PRINT FULL NAME                       SIGNATURE                     DATE




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