Incident Reporting Policy by 3VS5zGSN

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									                                                Lifeline Project




Incident Reporting Policy and Procedures




Policy Reviewed: February 2011   Page 1 of 22   Review Date: March 2012
Lead: Clinical Governance Lead                  Version: 2
                                                                   Lifeline Project
Scope

This policy covers all staff and volunteers employed by and seconded to the Lifeline Project.
It is offered as a guide to independent contractors (for example, sessional workers) offering
services to Lifeline clients. This policy and associated procedures replace the previous
accident and incident reporting procedures.

This policy includes guidance on managing Serious Untoward Incidents.

The policy and underpinning procedures aim to ensure that incidents are managed and
reported in an appropriate and timely manner and that lessons are learned to ensure that the
incident does not happen again.

Additional information can be found in Lifeline’s:

        Complaints Procedure
        Health and Safety Policy
        Blood Borne Virus Policy
        Infection Prevention and Control Policy

Introduction

There is a legal obligation under the Health and Safety at Work Act (1974) and other
associated legislation to report investigate and keep records of events that have caused
actual or potential injury, dangerous occurrences and occurrence of disease or ill-health.
(see Appendix one) Services that are registered with the Care Quality Commission (CQC)
are required to report certain categories of incidents to the Commission (See Appendix two),
and Lifeline Project may also be required to report some incidents to our insurers to ensure
that we are adequately covered. In addition, where Lifeline is contracted to deliver services
by statutory bodies (for example, Primary Care Trusts) there may be contractual obligations
to comply with that organisation’s incident reporting procedures.

The purpose of the incident reporting system is to identify problems, develop remedies and
minimise the chance of re-occurrence. It is essential that workers report all incidents and
near misses so that Lifeline can identify any patterns or trends. Establishing a central record
of all incidents, accidents and near misses will allow Lifeline to develop an understanding of
areas of risk across the organisation and to identify priorities for action across the
organisation to prevent recurrence of similar incidents.

Lifeline seeks to have an open culture where the aim is to learn from incidents. Therefore
investigations should focus on systems and processes rather than individuals. Formal
disciplinary action should not routinely follow an incident even if a mistake has been made.
Disciplinary action should only be necessary where there has been an act of malice, criminal
or gross or repeated professional misconduct.

The Lifeline Project is committed to working to continuously improve the quality of our
services to people affected by substance use. We recognise the importance of being able to
manage and control risks. This involves collecting and analysing information about any
untoward incident that adversely affects a Lifeline service user, member of staff or member
of the public.

Policy Reviewed: February 2011           Page 2 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                      Version: 2
                                                                      Lifeline Project
Responsibilities

Chief Executive

The Chief Executive is responsible for setting the standard for the entire organisation,
demonstrating commitment to a patient safety culture and ensuring that all senior managers
demonstrate the same commitment.

The Chief Executive will ensure that there are procedures and human resources in place to
respond quickly to all incidents and that the organisation is able to learn from such events
including “close calls” and near “misses.”

Clinical Governance Lead

The Lifeline Clinical Governance Lead will establish and maintain a central record of
incidents, accidents and near misses across the organisation.

The Clinical Governance Lead will advise on incident management and external notification
of incidents, as required, and ensure that Heads of Directorate and colleagues from central
support functions are aware of incidents that may require their specialist input.

The Clinical Governance Lead will prepare regular reports on incident numbers and trends
for Directorate and Board meetings.

Individual

All staff, including any person working on behalf of Lifeline, have a duty to immediately
report any incident that they are either involved in or discover including those that may not
have resulted in any harm to an individual or the organisation. An incident that does not
result in actual harm must still be reported if the potential for harm existed. If staff are unsure
what actions to take in relation to an incident they must contact the senior member of staff
on duty at the time.

All staff are responsible for being aware of and using the incident reporting procedures in
line with the guidance provided in this policy.

Definitions of Incidents

    -    An incident is:

Any adverse incident, event or circumstance which has caused or may cause personal injury;
client dissatisfaction; property loss or damage; damage to the financial standing or
reputation of Lifeline. Incidents also include near misses or close calls which are incidents
which did not lead to harm but could have done so.

    -    A clinical incident is:

Any adverse client incident, event or circumstances arising during care delivered by Lifeline
that could have or did lead to unintended or unexpected harm, loss or damage. Clinical
incidents include incidents which relate to prescribing incidents or errors. Clinical incidents
also include near misses which are clinical incidents which did not lead to harm but could
have done so.

Policy Reviewed: February 2011            Page 3 of 22                 Review Date: March 2012
Lead: Clinical Governance Lead                                         Version: 2
                                                                    Lifeline Project
    -    A Serious Untoward Incident is:

An accident, incident or series of events leading to serious injury, major permanent harm, or
unexpected death of a service user, the child of a service user, a member of staff or a
member of the public, in relation to services provided by Lifeline. It may also involve damage
to property or harm to the environment. It includes out of the ordinary or unexpected events
which have a serious effect on the care of service users or the management of Lifeline and
are likely to attract public or media attention. This also includes potential incidents or ‘near
misses’ which also require reporting.

    -    Service User Deaths:

Service User deaths should be reported under these procedures if they occur on Lifeline
premises or during sessions being led by Lifeline staff, if they are believed to be drug or
alcohol related or in any way connected with the care / treatment provided by Lifeline Project
(including all deaths of service users who were receiving medication prescribed through a
Lifeline service at the time of their death.)

External Reporting of Incidents

RIDDOR Reportable Incidents

RIDDOR is the reporting of Injuries, Diseases and Dangerous Occurrences Regulations
(1995) and is a statutory element of Health and Safety requirements. Whenever certain
events arise in connection with work they MUST be reported to the Local Authority within 10
working days and a record kept. If the event includes a fatal accident, a major injury, the
need for hospital treatment or a dangerous occurrence, the Local Authority should be
notified by the quickest practical measure, e.g. by telephone.

All managers must understand our obligations to report under RIDDOR. For details of what
events need to be reported see Appendix one.

Reporting to the Primary Care Trusts and Commissioners

Where Lifeline services are commissioned by Primary Care Trusts, the Clinical Governance
arrangements between Lifeline and the PCT may require that certain clinical and serious
incidents are reported through the PCT’s own reporting procedures

Lifeline may also need to report certain incidents to commissioners. This includes deaths in
treatment which may become the subject of Confidential Inquiries. It also includes incidents
or events which may cause reputational damage.

Care Quality Commission

The Care Quality Commission require notification where a service user dies in a CQC
registered service whilst services were being provided or as a consequence of the care that
was provided. CQC registered services are also required to notify the Commission if any of
the following occur in the service or as a consequence of the care or treatment delivered:

        Incidents resulting in a serious injury to a Service User (see Appendix 2 for
         definitions of serious injuries)

Policy Reviewed: February 2011           Page 4 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                      Version: 2
                                                                        Lifeline Project
        Abuse or allegations of abuse
        Incidents that are reported to the police
        Incidents that prevent the service from being able to deliver care or treatment for a
         significant period of time (usually over 24 hours)

Incident Reporting Procedures

Managing and Reporting Accidents, Incidents and Near Misses

All incidents, accidents and near misses should be reported to a team leader and Lifeline
Project’s Clinical Governance Lead as soon as possible, according to the procedure outlined
below and in Appendix four, using the template shown in Appendix five. As well as
reporting to Lifeline’s central reporting inbox, a full record of all incidents, accidents and near
misses should be held at the service, and any information that is relevant to the care and
treatment of individual service users should be recorded in their files. An example of a form
that can be used for local incident reporting is included at Appendix six. Every employee
has a duty to report incidents and accidents occurring in connection with work. All Lifeline
departments should identify a local Manager with lead responsibility for Clinical Governance.
Where services are subject to Care Quality Commission registration this will usually be the
Registered Manager.

Any accident, incident or near miss should be reported using the Serious Incident Procedure
below.

        When reporting an incident, only known facts should be reported and not opinions
        Complete the Lifeline Project Incident Report template and e-mail to the Lifeline
         Incident and Complaint reporting e-mail address.
        This should be completed as soon as possible, and in most cases this will be within
         24 hours of the incident occurring.
        This template was designed to include the minimum necessary information to
         support Lifeline Project’s Clinical Governance Framework, and can be used in
         combination with other local reporting requirements if necessary.
        If the accident or incident resulted in actual physical injury, ensure that full details are
         recorded and held at the service (for example in an Accident/Injury Record book.)
        All reporting of RIDDOR incidents should be completed by a Service or Senior
         Manager with advice from the Clinical Governance Lead Manager and the Clinical
         Governance Lead. N.B Any incident or accident that results in a member of staff
         having more than 3 days sickness absence including weekends will need to be
         reported to RIDDOR, so must be reported to the Clinical Governance Lead
         immediately.
        The Clinical Governance Lead will advise on investigation, external notification and
         appropriate action to manage risks, as appropriate and when required.
        The Clinical Governance Lead will ensure that a central record is maintained of all
         accident and incident reports, investigations and actions taken to manage risks, and
         will use this to prepare regular reports to the Lifeline Project Directorate and Board
         Meetings.
        The manager registered with the Care Quality Commission holds the responsibility
         for notifying them directly and without delay in the event of a service user death and

Policy Reviewed: February 2011             Page 5 of 22                 Review Date: March 2012
Lead: Clinical Governance Lead                                          Version: 2
                                                                  Lifeline Project
         other notifiable incidents outlined above. Such notifications must contain a unique
         code or ID number for all Service Users mentioned, and not provide any personally
         attributable information.

Guidance for managing and reporting incidents

When an incident has happened it is important that:

        The immediate needs of the client and any others involved are dealt with. If you are
         unable to do this, seek help immediately.
        The environment is made safe to prevent further incidents and to safeguard others
         where appropriate.
        All evidence relating to the incident is retained.
        Any defective equipment is withdrawn from use.
        Advice about keeping evidence safe and withdrawing equipment should be obtained
         from the manager of the service involved as soon as possible after an incident.
        Following an incident, those involved should be de-briefed by a senior staff member
         and offered or referred for appropriate follow-up support

When reporting an incident only known facts and not opinions must be given. When filling
out the incident report template please read the instructions contained in the form and then
complete all sections:

        Date of the incident
        The service name
        Where the incident occurred
        The name of the main person involved (if more than one person was involved, this
         will be the person who was the main instigator of the incident)
        The role of this person
        The category of the incident (selection from a list)
        A brief description of the incident, action taken to manage the incident and further
         actions required
        Whether anybody was injured and, if so, brief details of the injury and treatment
         provided
        Which external bodies the incident has been reported to
        The name and contact telephone number of the person reporting the incident

Once the above sections of the report have been completed the incident report must be
emailed to the Clinical Governance Lead, within 24 hours of the incident wherever possible.

The full process for reporting and managing incidents, accidents and near misses is outlined
in Appendix three.

Roles and responsibilities in managing and reporting accidents, incidents and
clinical incidents

All staff are responsible for being aware of and using the incident reporting procedures in
line with the above guidance.


Policy Reviewed: February 2011          Page 6 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                     Version: 2
                                                                  Lifeline Project
Service or Senior Managers are responsible for completing reports of RIDDOR incidents, as
advised by the local Clinical Governance Lead Manager, and keeping the Senior Manager or
Head of Directorate informed.

Service Managers along with the Senior Manager or Head of Directorate are responsible for
reviewing all incidents on a quarterly basis and ensuring that appropriate actions have been
implemented.

Lifeline’s Clinical Governance Lead is responsible for reviewing the learning from clinical
incidents with Heads of Directorate, disseminating relevant information across the
organisation and ensuring that recommended actions are implemented.

The Clinical Governance Lead is responsible for producing regular reports on all accidents,
incidents and near misses for the Directorate team and Board Meetings.

The local Clinical Governance Lead Manager is responsible for reporting clinical incidents
and serious incidents to the PCT (and other relevant bodies) using the PCT reporting
procedures, in line with contractual obligations.

The CQC Registered Manager is responsible for reporting relevant incidents to the Care
Quality Commission, with advice and support from the Lifeline Clinical Governance Lead, if
required.

The Senior Manager or Head of Directorate is responsible for reporting client deaths to
commissioners and for ensuring that Lifeline is represented at Confidential Inquiries
following a Drug Related Death.

In the event of a serious incident, the Head of Directorate is responsible for informing the
CEO immediately and reporting to the CEO the outcome and recommendations of any
investigation.

The Service or Senior Manager is responsible for communicating appropriately with clients,
families, partner agencies and informing regulatory bodies where applicable.

Managing and Reporting a Serious Untoward Incident

A Serious Untoward Incident is one where actual or potential major harm or death has
occurred. In such a case staff involved should manage the incident and immediately report
to the Service or Senior Manager, who must inform the Senior Manager or Head of
Directorate. The incident report should be completed as above and the report emailed
immediately to the Clinical Governance Lead. The Senior Manager/Head of Directorate must
inform the Chief Executive.

The Senior Manager should also communicate as appropriate with any relevant parties such
as clients or relatives affected by the incident and inform commissioners as appropriate. The
local Clinical Governance Lead Manager leads investigation of the incident and oversees
development of an action plan, with support and oversight from the Clinical Governance
Lead and other central support teams as required.

The Senior Manager reports the action plan to the CEO and commissioners and
communicates with clients and families and relevant others.

Policy Reviewed: February 2011         Page 7 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                    Version: 2
                                                                     Lifeline Project
The following list provides examples of incidents which might meet the criteria for a SUI.

        Sudden unexpected death of a service user
        Death of a child in the care of the service user
        Serious assault by a service user
        Serious self-harm by a service user
        Death or serious injury of a service user member of staff, the public whilst on Lifeline
         premises
        Serious breach of confidentiality
        Serious medicines errors
        Serious physical damage to premises
        Serious concerns for safety of service users
        Serious adult protection issues
        Serious child protection breaches
        Possible media attention




Policy Reviewed: February 2011            Page 8 of 22                Review Date: March 2012
Lead: Clinical Governance Lead                                        Version: 2
                                                                    Lifeline Project


Appendix 1: REPORTING OBLIGATIONS UNDER
RIDDOR (Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995)


What events need to be reported under RIDDOR?

Whenever any of the following events arises out of or in connection with work it must be
reported to Local Authority in writing within 10 days and a record kept. If the event involves a
fatal accident, a major injury, the need for hospital treatment or was a dangerous occurrence
the Local Authority must first be notified by the quickest practicable means e. g. by
telephone:-

         1.   The death of any person as a result of an accident, whether or not they are
              at work

         2. Someone who is at work suffers a major injury as a result of an accident.
            These are;
             Fracture other than to fingers, thumbs or toes
             Amputation
             Dislocation of the shoulder, hip, knee or spine
             Loss of sight (temporary or permanent)
             Chemical or hot metal burn to the eye or any penetrating injury to the eye
             Injury resulting from an electric shock or electrical burn leading to
               unconsciousness or requiring resuscitation or admittance to hospital for more
               than 24 hours
             Any other injury; leading to hypothermia, heat induced illness or
               unconsciousness; or requiring resuscitation; or requiring admittance to
               hospital for more than 24 hrs.
             Unconsciousness caused by asphyxia or exposure to harmful substance or
               biological agent
             Acute illness requiring medical treatment or loss of consciousness arising
               from absorption of any substance by inhalation, ingestion or through the skin
             Acute illness requiring medical treatment where there is reason to believe that
               this resulted from exposure to a biological agent or its toxins or infected
               material

         3. Someone who is not at work (e. g. a member of the public) suffers an injury
            as a result of an accident and is taken from the scene to a hospital

         4.   One of a list of specified dangerous occurrences takes place.
              Dangerous occurrences are events which do not necessarily result in a
              reportable injury, but have the potential to cause significant harm.
Policy Reviewed: February 2011           Page 9 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                      Version: 2
                                                                     Lifeline Project

                  These are;

                 Collapse, overturning or failure of load-bearing parts of lifts and lifting
                  equipment
                 Explosion, collapse or bursting of any closed vessel or associated pipe work
                 Failure of any freight container in any of its load bearing parts
                 Plant or equipment coming into contact with overhead power lines
                 Electrical short circuit or overload causing fire or explosion
                 Any unintentional explosion, misfire, failure or demolition to cause the
                  intended collapse, projection of material beyond a site boundary, injury
                  caused by an explosion
                 Accidental release of a biological agent likely to cause severe human illness
                 Failure of industrial radiography or irradiation equipment to de-energise or
                  return to its safe position after the intended exposure period
                 Malfunction of breathing apparatus while in use or during testing immediately
                  before use
                 Failure or endangering of diving equipment, the trapping of a diver, an
                  explosion near a diver or an uncontrolled ascent
                 Collapse or partial collapse of a scaffold over five meters high, or erected
                  near water where there could be a risk of drowning after a fall
                 Unintended collision of a train with any vehicle
                 Dangerous occurrence at a well
                 Dangerous occurrence at a pipeline
                 Failure of any load bearing fairground equipment, or derailment or unintended
                  collision of cars or trains
                 A road tanker carrying a dangerous substance overturns, suffers serious
                  damage, catches fire or the substance is released
                 A dangerous substance being conveyed by road is involved in a fire or
                  released
                 Unintended collapse of any building or structure under construction,
                  alternation or demolition where over five tonnes of material falls, a wall or
                  floor in a place of work
                 Explosion or fire causing suspension of normal work for over 24hrs.

5.       Someone at work is unable to do the full range of their normal duties for more
         than three days as a result of an injury caused by an accident at work. For
         example, a case where an employee suffered shock and was off work as a result of
         witnessing an act of violence or abusive or threatening behaviour would not need to
         be reported. However, cases where a worker suffered shock and was unable to carry
         out the full range of their normal duties for over three days because of a physical
         injury received as result of an act of violence would be reportable. That is to say, the
         incapacity must arise from the physical injury and not be the result of a psychological
         reaction to the act of violence alone. Please tote: An act of violence done to a
         member of the public by an employee or another member of the public would not be
         regarded as an accident and any resulting injury would not need to be reported


Policy Reviewed: February 2011            Page 10 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                        Version: 2
                                                                    Lifeline Project
6.       The death of an employee if this occurs some time after a reportable injury
         which led to that employee’s death, but not more than one year afterwards

7.       A person at work suffers one of the following specified diseases

        Certain poisonings
        Some skin diseases such as occupational dermatitis, skin cancer, chrome ulcer, oil
         folliculitis/acne
        Lung disease including occupational asthma, farmer’s lung, pneumoconiosis,
         asbestosis, mesothelioma
        Infections such as leptospirosis, hepatitis, tuberculosis, anthrax, legionellosis and
         tetanus
        Other conditions such as: occupational cancer, certain musculoskeletal disorders,
         decompression illness and hard-arm vibration syndrome

Determining if an accident is reportable under RIDDOR does not depend on apportioning
blame. The broad meaning of ‘arising out of or in connection with work’ means that an
accident may still be reportable even if there has been no breach of health and safety law
and no one was clearly to blame.

What does ‘arising out of or in connection with work’ mean?

Regulation 3 of RIDDOR requires events to be reported where they arise out of or in
connection with work. Although it is essential to understand this phrase when deciding
whether an accident should reported there is no definition provided in the Regulations. HSE
guidelines recommend that when deciding whether an accident is reportable employers
should consider the following questions:

        What work was going on at the time?
        What was the injured person doing?
        What were others doing?
        Where did the accident happen?

Having regard to those guidelines the following incidents would be reportable where it
results in a fatality or a major or over 3 day injury:

        A manager is hit by an employee while giving an instruction to carry out a work
         related task
        A member of a hospital medical team is hit by a client while carrying out their duties
        A new employee is injured while being forced to take part in an initiation ceremony

Injuries suffered by people in the following examples would not be regarded as arising out of
or in connection with work and so would not have to be reported:

        An employee hits a colleague during an argument over a personal matter
        An employee working at a public enquiry desk is hit by one of their relatives who
         comes in to discuss a domestic matter.

What records do you need to keep?


Policy Reviewed: February 2011           Page 11 of 22              Review Date: March 2012
Lead: Clinical Governance Lead                                      Version: 2
                                                                     Lifeline Project
You must keep a record of any fatality, reportable injury, disease or dangerous occurrence
for three years after the date on which it happened. This must include:

Incidents must be reported using the form F2580 which can be down loaded from the Health
& Safety Executive Website www.hse.gov.uk

Events involving people not at work

There is a duty to report accidents to persons not at work if the event arose out of work
activities. Below are examples of incidents involving people not at work which would be
reportable if they were to result in a fatality or the injured person had to be taken to hospital.

        Someone shopping who was involved in an accident at an escalator in a shop, where
         the accident was attributable to the design or condition of the escalator
        A resident in a care home trips and falls over an electric cable which is lying across
         the floor in the home.
        A member of the public is injured visiting a factory when fumes escape from a
         process being carried on there.



For more information on RIDDOR, please see: http://www.hse.gov.uk/riddor/index.htm




Policy Reviewed: February 2011           Page 12 of 22                Review Date: March 2012
Lead: Clinical Governance Lead                                        Version: 2
                                                                    Lifeline Project


Appendix 2: Summary of reporting requirements to
Care Quality Commission
The kinds of incidents and events that must be notified to the Care Quality Commission are:

        Service User deaths occurring whilst services are being provided or as a
         consequence of care and treatment provided
        Serious injuries to service users occurring whilst services are being provided or as a
         consequence of care and treatment provided
        Abuse or allegations of abuse
        Incidents that are notified to the police
        Incidents that prevent the service from operating for a significant period of time

Serious Injuries

Providers tell the Care Quality Commission without delay about events that lead to:

        Serious injury to any person who uses the service.
        An injury requiring treatment by a healthcare professional to avoid death or serious
         injury.

These serious injuries include:

        Injuries that lead to or are likely to lead to permanent damage – or damage that lasts
         or is likely to last more than 28 days – to:
             o A person’s sight, hearing, touch, smell or taste
             o Any major organ of the body (including the brain and skin)
             o Bones
             o Muscles, tendons, joints or vessels
             o Intellectual functions, such as
             o Intelligence
             o Speech
             o Thinking
             o Remembering
        The development after admission of a pressure sore of grade 3 or above that
         develops after the person has started to use the service (European Pressure Ulcer
         Advisory Panel Grading)
        Any injury or other event that causes a person pain lasting or likely to last for more
         than 28 days
        Any injury that requires treatment by a healthcare professional in order to prevent:
             o Death
             o Permanent injury
             o Any of the outcomes, harms or pain described above.
        Events that stop or may stop the registered person from running the service safely
         and properly
Policy Reviewed: February 2011           Page 13 of 22              Review Date: March 2012
Lead: Clinical Governance Lead                                      Version: 2
                                                                   Lifeline Project
    Abuse or Allegations of abuse

Providers inform the Care Quality Commission without delay of:

        Any suspicion, concern or allegation from any source that a person using the service
         has been or is being abused, or is abusing another person (of any age

    Incidents that are notified to the police

Providers inform the Care Quality Commission without delay of:

Any incident reported to or investigated by the police that is associated with the delivery of
the service and affects or may affect the health, safety and welfare of a person using the
service, its staff, or anyone who visits the service. These events include:

        people who use services going missing
        assault or malicious damage
        theft of property or money belonging to people who use the service.

Events that stop or may stop the service from operating safely and properly

Providers inform the Care Quality Commission without delay about:

        A level of staff absence or vacancy, or damage to the services’ premises, that mean
         that people’s assessed needs cannot be met.
        The failure of a utility for more than 24 hours
        The failure of fire alarms, call systems or other safety-related equipment for more
         than 24 hours
        Any other circumstances or events that mean the service cannot or may not be able
         to meet people’s assessed needs safely.

Notification Forms

Separate forms are used for reporting each category of incident to the Care Quality
Commission. These forms, as well as further guidance on reporting incidents to the Care
Quality Commission can be found at:

http://www.cqc.org.uk/guidanceforprofessionals/adultsocialcare/registration/notifications.cfm




Policy Reviewed: February 2011          Page 14 of 22              Review Date: March 2012
Lead: Clinical Governance Lead                                     Version: 2
                                                                             Lifeline Project

Appendix 3: Incident Management Flowchart


                                 The incident is reported immediately to Team Leader/
                                                    Service Manager


                                 The incident is reported according to Lifeline’s central
                                  incident reporting process (see Incident Reporting
                                                         Policy)



                                                                      Service or senior manager
             Service or Senior Manager                                    informs PCT Lead
            reports accident to RIDDOR,
                     if necessary



                                                                        CQC Registered Manager
    Service or Senior Manager informs                                    informs CQC if required
   commissioners/external bodies within                                  (see Incident Reporting
          contractual timescale                                                  Policy)




                                         Investigation
        Service or Senior Manager arranges investigation and ensures recommendations
        from action plan are implemented

        Service or Senior Manager ensures learning is discussed and shared with local
        managers and staff

        Lifeline’s Clinical Governance Lead provides support and oversight



    Outcome and actions implemented and                         Service or Senior Manager sends report to
     reported to Clinical Governance Lead                         commissioners/external bodies within
                    and CEO                                                 agreed timescale


         Regular reports of incidents and                             Service or Senior Manager
       lessons learnt completed by Clinical                        communicates with clients/ families/
                Governance Lead                                              other parties




Policy Reviewed: February 2011                  Page 15 of 22                Review Date: March 2012
Lead: Clinical Governance Lead                                               Version: 2
                                                                        Lifeline Project
Appendix 4: Central Incident Reporting Process


           Lifeline Project Central Reporting of Accidents and
                                 Incidents



                                 Incident, accident or near miss occurs


                  Make situation safe, take immediate action required to
                                  manage the incident


                    Incident report form sent to Central Lifeline mailbox


                                                               Other local and external
                                                            reports completed as required


           Incident report form forwarded to Head of Directorate

           Advice given on incident management and external reporting,
           where required

           Additional information requested, if needed

           Incident report form uploaded into database
                Managers oversee                              Information from database
              completion of actions to                       analysed and used to inform
               manage the incident                             action plans and strategy




Policy Reviewed: February 2011              Page 16 of 22               Review Date: March 2012
Lead: Clinical Governance Lead                                          Version: 2
                                                 Lifeline Project


Appendix 5 Central Incident Reporting Form




Policy Reviewed: February 2011   Page 17 of 22   Review Date: March 2012
Lead: Clinical Governance Lead                   Version: 2
                                                                Lifeline Project

Appendix 6: Example Local Incident Form


SECTION 1a: DETAILS OF INCIDENT


Date of incident                                  Time of incident:



Location of
incident ………………………………………………………………………………………………...


Address ……………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………….




Description: (Please report FACTS not OPINIONS)

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

……………………………………………………………………………………………………………………….

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SECTION 1b: WAS THE ACCIDENT / INCIDENT ANY OF THE FOLLOWING?
……………………………………………………………………………………………………………………….
Please tick a box
……………………………………………………………………………………………………………………….
HAZARD:
                                 □
                          Where a hazard has been identified and the potential for injury or
               damage exists
……………………………………………………………………………………………………………………….
DAMAGE ONLY:                     □
               Damage to property or equipment, or defective medical devices or
……………………………………………………………………………………………………………………….
               drugs or medicine (GO TO SECTION 3)
FIRST – AID:   Minor injuries whereby self – administered or first aid treatment was
What action has been taken?      □
               sufficient include minor emotional trauma (GO TO SECTION 2)
………………………………………………………………………………………………………………............
MEDICAL:
                                 □
               Any injury requiring professional medical attention (GO TO
……………………………………………………………………………………………………………………….
               SECTION 2)
……………………………………………………………………………………………………………………….
Policy Reviewed: February 2011         Page18 of 22                       Review Date: March 2012
……………………………………………………………………………………………………………………….
Lead: Clinical Governance Lead           Version 2.0


……………………………………………………………………………………………………………………….
                                                                               Lifeline Project
SECTION 2: DETAILS OF INJURED PERSON (may be required under RIDDOR)

TO BE COMPLETED IF ANY PERSON WAS INJURED OR CONSEQUENTLY SUFFERED ILL HEALTH

NB: If more than one person has been injured fill in a separate report for each person.



Name of injured person: …….......................................
                                                                    Male   □                Female    □

                                                                    Date of birth: ………………………………
Home address: ……………………………………….
                                                                    Age:………………………………………..
……………………………………………..................

………………………………………………………..

Post code: …………………………………………….

Home contact number:                                                Employee No:

WAS THE INJURED PERSON:

Please tick a box

A: Member of staff
                                          □         Complete all of section 2B. Clinical Governance Lead
                                                    Manager to determine if RIDDOR reportable.
B: Contractor
                                          □         (Not a Lifeline staff member/secondee). NB: Contractors
                                                    are responsible for own RIDDOR
C: Client:
                                          □         Injury / illness a result of what we have done, or failed to
                                                    do in the course of our work.
D: Member of the public
                                          □         On Lifeline property or injury a result of what we have
                                                    done, or failed to do in the course of our work.
E: Other
                                          □         Please describe:




SECTION 2B: INJURY DETAILS
Include type of injury (e.g. bruising broken bones, concussion etc)

…………………………………………………………………………….                                                      Parts of body affected

…………………………………………………………………………….

…………………………………………………………………………….

LOST TIME (Please tick a box)                                                       How many days unfit for
                                                                                    work?


Policy Reviewed: February 2011                    Page19 of 22                              Review Date: March 2012
Lead: Clinical Governance Lead                                                                           Version 2.0
                                                                  Lifeline Project
Did the injury or illness result in time off work    □ Yes □ No
If lost time occurred, how many full calendar days, including week ends
and holidays, was the person unfit for work? The day of the incident is
not counted as a full day.




Policy Reviewed: February 2011                Page20 of 22                  Review Date: March 2012
Lead: Clinical Governance Lead                                                           Version 2.0
                                                                    Lifeline Project


SECTION 3: PROPERTY / EQUIPMENT / MEDICINES
To be completed if the incident relates to any damaged or faulty property or equipment, problems with
drugs or medicines.

OBJECT …………………………………………………………………………………………………………...

………………………………………………………………………………………………………………………

Location of quarantined equipment ……………………………………………………………………………..


Quarantined = clearly labeled, packaged and secured (locked away) as evidence

PROBLEM: ……………………………………………………………………………………………...............

……………………………………………………………………………………………………………………..

……………………………………………………………………………………………………………………..



SECTION 4: CATEGORIES
Please tick a box

                                               Any incident relayed to the client’s status, treatment or
1: Clinical incident
                                       □       care.
2: Equipment
                                       □       Incident involving equipment.

3: Falls
                                       □       All slips, trips and falls, including client falls.

4: Manual handling
                                       □       Any incident involving moving and handling which
                                               results in damage or harm.
5: Contamination (needlestick)
                                       □       Biological or chemical hazards.

6: Road Traffic Accident
                                       □       Driving at work (not to and from home). Reportable by
                                               driver to police under Road Traffic Act.
7: Violence / abuse / harassment
                                       □       Verbal abuse, unsociable behaviour, racial or sexual
                                               harassment, physical assault.
8: Personal accidents (other)
                                       □       Any incident, no matter how small, which either did or
                                               could have had an adverse effect on a person.
9: Failure to warn (Consent)
                                       □       Non compliance with Lifeline Consent Policies.

10: Self harm/suicide/fatality
                                       □       Self harm, suicide or fatality on Lifeline property.

11: Wrong diagnosis
                                       □       All incidents of wrong diagnosis, suspected or actual,
                                               regardless of outcome.
12: Security
                                       □       Theft, loss, trespass, vandalism to Lifeline property

13: Medication error
                                       □       Incident, error or concern involving prescribing or
                                               dispensing of medication

Policy Reviewed: February 2011           Page21 of 22                                   Review Date: March 2012
Lead: Clinical Governance Lead                                                                       Version 2.0
                                                                     Lifeline Project
14: Dangerous Occurrence (Estates)
                                         □       Fire, flood, explosion, structural failure etc.

15: Other
                                         □       All other incidents that you cannot categorize.
                                                 Please describe:




SECTION 5: YOUR DETAILS
Details of person completing this part of the form:


Name: …………………………………….....................................Date: ……………………………………


Job title: …………………………………………………………… Contact No: …………………………….


Place of work: ………………………………………………………….




Policy Reviewed: February 2011             Page22 of 22                                Review Date: March 2012
Lead: Clinical Governance Lead                                                                      Version 2.0

								
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