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Date of Last Review:   September 2007
Date of Next Review:   October 2009
Lead Director:    Director of Quality and Performance Improvement
Lead Manager:     Risk Manager

Incident /Near Miss Reporting And Management Policy Including
Serious Untoward Incidents (SUIs)
      Policy Statement                                             3

1.    Introduction                                                 4

2.    Rationale                                                    4

3.    Developing Safety Culture at Croydon Primary Care Trust      5

4.    Scope of Policy                                              6

5.    Who Does the Policy Apply to?                                6

6.    Definitions of Adverse Incidents                             7

7.    Roles and Responsibilities                                   7

8.    Confidentiality                                              8

9.    Communications                                               8

10.   Preservation of Evidence                                     8

11.   Counselling and Support to Patients, Staff and Other         9

12.   Equality of Treatment                                        9

13.   Training                                                     9

14.   Review of Policy                                             9

15.   Policy Audit                                                 9

16.   Other Related Documents                                      9
Appendix 1 - Definition Of Adverse Incidents                      13

Appendix 2 - Roles And Responsibilities                           16

Appendix 3 - Reports to Committees                                19

Appendix 4 – Incident Reporting Form


Policy Statement
Croydon Primary Care Trust (PCT) is committed to the provision and maintenance
of high quality care and services for residents of Croydon. This policy is designed
to provide guidance where an incident has occurred within the services provided at
the Primary Care Trust.

Through implementation of this policy, the PCT is doing its reasonable best to
prevent injury, ill health and harm to staff, patients, relatives and visitors as well as
safeguarding its assets and services.

As part of this commitment the PCT will ensure that a system is in place that will
enable all adverse incidents and near misses to be reported and investigated. This
will allow the PCT to determine the causal factors, rectify any faults, prevent re-
occurrence, and provide support and counselling where necessary. Also a key
commitment of the policy is to ensure that lessons are learnt from adverse
incidents and near misses and to ensure improved practice and reduction of risk of
future occurrences.

All adverse incidents including accidents, near misses, property damage,
equipment failure, verbal abuse and dangerous occurrence should be reported as
soon as possible after their occurrence, as set out in the adverse incident reporting

The PCT is committed to providing a supportive culture in which the raising of
concerns is viewed positively. There may, however, be situations when staff
members feel threatened or fear reprisals by raising concerns with their managers
or by using the Incident Reporting Procedure in a normal way. In that case, the
Procedure for Raising Concerns (Whistle blowing) should be used. Staff members
deliberately failing or avoiding to report adverse incidents could be subject to
disciplinary action.

All members of staff have an obligation to co-operate in full with this process and
all concerns, near misses and incidents must be reported.

1.     Introduction
In the course of providing health care, a range of incidents can occur, some of
which may have actual or potential serious consequences for the Croydon Primary
Care Trust (PCT). Consequence may include harm to service users, staff and
public, damage to assets and disruption to its services. The PCT has a
responsibility to make every effort to reduce the likelihood of incidents happening
again by investigating, understanding their root causes and taking appropriate
preventative action.

This policy sets out how incidents should be reported and responded to within the
organisation, in order to make the PCT a safer place for everybody. It sets out what
the PCT expects from staff members who may be involved in reporting and
managing incidents.

This policy is supported by detailed procedures which all staff are required
to be aware of and if need arises, follow them appropriately.

This policy was prepared in consultation with representatives from all Directorates
and consulted with all PCT staff after the review. The PCT recognises the
significant contribution made by the unions in supporting and advising staff.
Working in partnership, the PCT and unions are committed to ensuring that staff
receive the help and support they need when involved in an incident, from
whichever source most appropriate for the staff member concerned.

In drawing up of this policy, consideration has been given to the Human Rights Act
1998, and in particular Articles 6 and 7 as well as the Data Protection Act 1998 and
other relevant legislation. The aim of reporting incidents and that of investigations
is neither to apportion blame nor to discipline staff but to learn from them. The
policy addresses itself to the provision of support for staff involved in investigations
and the provision of appropriate information for others involved as to the outcomes
of investigations, whilst giving due consideration to issues of staff and patient
confidentiality. As such, the PCT believes that the policy is compliant with the
provisions of this statute.

2.     Rationale
The PCT aims to ensure that all kind of risks are minimised for the protection of
patients, staff, visitors, contractors and services through effective management of
risks. These include clinical, financial, health & safety and environmental risks.

Risk management is an essential element of corporate and clinical governance and
means of identifying and treating risks, exercising internal control and provision of
assurances to the Board that all risks are managed effectively.

Reporting of all adverse incidents within the PCT is an essential element of the risk
management strategy.
The purpose of the incident reporting system is to:

1. Enable prompt remedial action to be taken and prevent recurrence
2. Ensure that lessons are learned and communicated so that they can be used in
   the development of future safety strategies and safe systems of work
3. Fulfill the PCT’s legal and statutory obligation to record and report certain
   defined incidents including:
        Health & Safety at Work Act 1974 and also subsequent legislative
         requirements for reporting incidents.
        The reporting of Injuries, Diseases & Dangerous Occurrences Regulations
         (RIDDOR) 1995 requirements the PCT to report certain events, which arise
         out of or in connection with work
        The Medicine and Healthcare Products Regulatory Agency (MHRA)
         requirements for the PCT to report any adverse event involving medical
        The National Patient Safety Agency (NPSA) requires the PCT to report
         incidents within 45 days
        The NHS London requires the PCT to report all Serious Untoward Incidents
        Clinical Negligence Scheme for Trusts (CNST) and Risk Pooling Scheme
         (RPST) risk-management standards and Healthcare Commission
4. Assist in decision-making, planning and allocation of future resources
5. Identify conditions of health and safety and environmental risks and poor
   practices that may be prevented by suitable early management
6. Inform the risk management strategy and risk register
7. Provide statistical information for trend analysis
8. Provide an early warning for potential complaints or claims.

3.       Developing Safety Culture at Croydon Primary Care Trust
The PCT aims to develop an open, fair and learning culture and is committed to a
positive and non-punitive approach to incident reporting. The PCT sees incident
reporting to be essential for developing a safety culture. The purpose of this policy
is not to apportion blame to individuals but to ensure that individual, team and
organisational learning takes place from incidents and that future risks are
reduced. Putting a name on the incident form does not imply blame. It is important
that staff value the incident reporting system and feel encouraged to use it. It
should be used as a positive working tool towards achieving safe and secure
environment for the delivery of high quality care and services.

The PCT recognises that most incidents occur because of problems with systems
rather than individuals. Therefore, it is essential to separate incident investigation
process, which is aimed at probing the system, from the disciplinary process. The
following points spell out the relationship between incident reporting and


Reporting an incident, accident, a near miss or a care management problem does
not imply blame, admission of guilt or beginning of disciplinary action. However,
the PCT retains the right to initiate disciplinary procedure where:

     1. In view of the standards set by the PCT, Professional or other regulatory
        bodies, the actions of an individual causing an incident are far removed
        from an acceptable practice
     2. Where a prima-facie case of negligence or criminal act is identified, or the
        negligence, gross misconduct or breach of duty of care becomes known as
        a result of an investigation of a serious incident.
     3. Where a staff member repeatedly chooses to ignore incident reporting
        system and incidents are identified through other means e.g. complaints or
        a claim
     4. Where acts of omission are found to be intentional or criminal
     5. In case of malicious reporting or assault
     6. Where despite earlier intervention/s, there are further occurrences
        involving the same individual/s, which indicate that learning has not

     4.     Scope of Policy
This policy covers all adverse incidents and near misses, no matter who or what
may be involved or how serious or minor the incident associated with the services,
operations and business of the PCT and includes clinical, health and safety,
financial and environmental incidents. The principles adopted in this policy cover
all aspects of reporting, grading, handling, managing, investigating and learning
from adverse incidents and near misses. This will ensure all PCT staff adopt a
consistent approach to dealing with incidents and near misses.

This includes incidents involving patients, visitors, staff, those providing services
under service level agreement (SLA), volunteers, students, people on work
experience or secondment (temporary, agency and bank staff) and contractors.

In the event of a major incident such as disease outbreak, the prime concern is for
the PCT to respond quickly and effectively. The PCT’s Major Incident Plan details
the process for doing this. The investigation procedures and the principle of
learning from an incident, however, still apply.

5.        Whom Does the Policy Apply to?
This policy applies to everyone employed by the PCT, wherever they are based
and anyone working on or visiting PCT premises or places where the PCT provides
healthcare services in whatever capacity (such as within the community).

Seconded Staff, Contractors and Joint Services
This policy also includes staff seconded to work at the PCT and staff providing
services under contract. These staff groups must also consider the need to comply
with their own workplace’s and employers reporting requirements. Similarly PCT
staff working within multi-agency teams will need to comply with partner agencies
policy and reporting requirements.

Where joint health and social care is involved, the responsible director will ensure
that appropriate structures and processes are in place to enable joint investigation
and shared learning around incidents.

Primary Care Independent Contractors
Primary Care contractors are responsible for reporting adverse incidents through
quarterly significant event audits as part of their arrangements with the PCT. This
currently applies to all independent contractors. The PCT will work with primary
care contractors to facilitate this process.

The PCT encourages patients, carers and visitors to report incidents that occur.
Only by having a clear understanding of all incidents will the PCT be able to
develop an appropriate response to the risks that face the organisation, its staff
and the public. It is the responsibility of the lead director to ensure that there are
clear instructions for patients, carers and visitors on each of the PCT sites on how
to report incidents.

6.      Definitions of an Incident
An adverse incident is an unwanted, unplanned, or unexpected event or accident
that may or may not result in physical injury, loss or damage or the risk thereof. It
may be a single or multiple events caused by unsafe acts, unsafe conditions or

In order to manage and investigate an adverse incident appropriately it may be
divided into:

    Near miss
    Minor adverse incident
    Serious untoward incident
    Major incident

Details of definitions and categorisation are given in appendix 1 and in the detailed

7.      Roles and Responsibilities
There are clear roles and responsibilities in relation to reporting / managing and
investigating adverse incidents. These are set out in appendix 2 as supported by

the detailed procedures.

8.     Confidentiality
Staff Confidentiality
To ensure effective staff participation in the incident reporting procedure the PCT
will provide a confidential reporting system which is non-threatening and

Where a clinical incident has occurred, the incident report shall not become part of
the patient’s Health Record to protect the confidentiality of the reporter and third
parties. However, contemporaneous record of events and how they were
managed should be recorded in the Health Record.

The staff responsible for keeping the incident reporting forms (books) must ensure
their safety and security. The copies of completed (used) incident forms should not
be made available to any staff member without authorisation.

As a general rule, it is the responsibility of all staff to maintain confidentiality of staff
members and third parties except where information has to be disclosed for
administrative or legal reasons.

Patient Confidentiality
It is common law and professional duty of all staff members to preserve
confidentiality of patient information at all times. Staff must adhere to the Caldicott
principles and Staff Code of Conduct regarding the transfer of patient- identifiable
information within the PCT and to other partner agencies.

Where disclosure of information is essential to partner agencies, staff will follow the
information sharing protocols governing the protection and use of patient-
identifiable information.

When transferring patient identifiable information it is the responsibility of staff
members to ensure that the means of transfer used, whether verbal, written or
electronic is physically secure.

9. Communication
The PCT recognises that effective communication and openness are key to the
management of adverse incidents and near miss. This includes prompt
communication with internal and external stakeholders i.e. its staff, patients/service
users, relatives/carers, NHS London and other partner agencies.

10.    Preservation of Evidence
In the event of an adverse incident all evidence must be preserved until the
necessary advice has been sought or the outcome of the investigation/testing is
known. For example, in the event of a cold chain break such as a vaccine fridge
alarming, all vaccines should be preserved and advice sought from the pharmacy


In the event of a Serious Untoward Incident (SUI) including that which involves a
suspected criminal act, evidence must be preserved. No action must be taken to
clean up an area until the police have arrived. It is the responsibility of staff at the
site of incident to preserve any evidence until the scene of crime officers completes
their investigations.

If a medical device or defective equipment has led to an incident it must be taken
out of use and preserved until further investigations have taken place.

11.     Counselling and Support to Patients, Staff and Others
The PCT will put arrangements in place for providing support to service users, staff
and others affected by an incident or for any other reason feel the need for help.
Where a member of staff has been involved in an incident, the line manager has
the responsibility for making arrangements for counselling if required. The lead
clinician responsible for a patient’s care will be responsible for arranging
counselling the service users involved in the incident.

12.     Equality of Treatment
When dealing with staff involved in adverse incidents and accidents, the PCT will
treat all staff with equality, irrespective of their profession, grade, work location and
all other aspects of diversity.

13.     Training
The PCT is committed to the continuous development of its staff. A range of
training programmes will be developed to support staff in the risk management
agenda, including how to manage, report, analyse and learn from incidents.

14.     Review of Policy
The policy will be reviewed annually and in addition in response to changes in
legislation, policy directives, or any other relevant event.

15.     Policy Audit
A PCT wide audit will be undertaken twelve months after the ratification of this
policy. Reports of incident investigations and trend analysis of incidents will be
submitted to the appropriate committees within the Trust as set out in the table in
appendix 3.

16.     Other Related Documents
Procedures for Reporting and Managing Incidents/Near Miss including SUIs
These provide detailed and step-by-step guidance to deal with an incident. All staff
and particularly managers should familiarise themselves with these procedures.

Governance Strategy

Governance arrangements ensure NHS organisation’s accountability, probity and
transparency; including continuously improving the quality of their services and
safeguarding high standards of care. The reporting, analysing and learning from
clinical incidents is key to identifying risks related to poor clinical practice and
improving clinical practice.

Complaints Policy
Sometimes an incident may give rise to a complaint. A complaint may be
investigated as an SUI and there is no need for separate investigation where one is
already underway. The Assistant Director of Quality and PPI will need to be kept
fully informed with the progress of the investigation of individual complaints.

Disciplinary And Appeals Incorporating Suspension Policy and Procedure
The aim of this policy and procedure is to uphold the high standards of conduct
required by the Trust and to provide a fair and consistent method of dealing with
breaches of these standards. The Trust’s Code of Requirements provides
guidance on the standards expected.

Health & Safety at Work Policy
The policy promotes a safe environment for staff and patients, and provides
guidance and procedures for the organisation.

Legal Claims
The PCT is liable for the actions of its employees in the legitimate course of their
employment. It is essential that the Risk Manager, Executive Nurse and Director of
Quality and Performance Improvement are given early warning of incidents, which
may lead to potential negligence claims. Civil Litigation Reforms require that the
PCT must investigate incidents in preparation for litigation. The incident reporting
system is therefore crucial to the good management of claims.

Major Incident Plan
Croydon Primary Care Trust (PCT) has a duty to protect and promote the health of
the community, including at times of emergency. It is committed to ensuring it can
respond quickly and effectively to any major incident. The PCT’s Major Incident
Plan details how it will do this.

Procedure for Raising Concerns (Whistle blowing)
This procedure was introduced to enable staff to raise concerns at an early stage if
they have concerns at work. Usually these concerns are easily resolved.
However, when they are about unlawful conduct, financial irregularity or concern
about the clinical competence of another clinician, it can be difficult to know what to
do. This procedure provides guidance for staff in these circumstances.

Risk Management Strategy
The Risk Management Strategy describes the approach to be adopted by Croydon
Primary Care Trust for managing risks and achieving compliance with risk

management standards. The successful managing, reporting, analysing and
learning from incidents in order to reduce risk are a key objective of this strategy.

Being Open Policy: When Patients are harmed
Being open, as defined by the National Patient Agency (NPSA), simply means
apologising and explaining to patients and/or their carers as to what happened if
someone was harmed receiving treatment.

Being Open policy complements Croydon PCT’s current Policy and Procedure for
Reporting and Managing Incidents including Serious Untoward Incidents (SUIs),
and reaffirms the PCT’s commitment to openness, as well as clarifying the process
for staff on extending apologies to patients and /or their carers who are harmed as
a result of their treatment. Being Open policy aims to improve the quality and
consistency of communication with patients and/or their carers. In doing so, it can
reduce trauma suffered by patients and potentially reduce complaints and claims.

Claims Handling and Management Policy
The policy and procedures outline the key principles and process by which claims
will be handled by Croydon PCT, ensuring best professional practice at local level.
This includes clinical negligence, employer’s liability and third party claims. This is
keeping in line with civil litigation requirements and CNST guidelines issued by the
NHS Litigation Authority, which are to be implemented from 1st January 2007. The
Claims Handling Policy will ensure that health care governance issues are
addressed and robust investigations are carried out as required by the Incident
Reporting Policy and procedures.

Reporting Serious Untoward Incidents - Joint Policy and Procedure for
Commissioned Services
The PCT’s lead commissioning role for Croydon, the requirements of
Commissioning a Patient Led (CaPL) NHS and implementation of Healthcare
Commission standards have given a particular emphasis to the PCT’s
responsibility for ensuring the safety and quality of commissioned services. The
Board therefore, needs to be aware of all Serious Untoward Incidents (SUIs) that
occur in commissioned services and involve Croydon residents. It is necessary for
the PCT to address areas of common concern and to discharge its responsibilities
as a commissioner effectively. Information on SUIs enable the PCT to respond to
public concerns and press queries in an appropriate and timely manner.

NHS London - Serious Untoward Incident (SUI) Reporting Guidance
NHS London needs to receive information on Serious Untoward Incidents (SUIs)
from NHS organizations within its boundaries in order to both identify learning
opportunities for improving patient safety, and to ensure that NHS Trusts and
Primary Care Trusts (PCTs) have robust arrangements in place to investigate
incidents and prevent reoccurrence. This Guidance establishes a level of

consistency over what type of incident should be reported and the level of severity
it should be. It also summarises how SUI reporting links in with investigation

It provides clarification on roles and responsibilities and describes the
recommended reporting mechanism. It indicates reporting flow channels both
between organisations and within the Strategic Health Authority (SHA).
It is designed to address the expectations of PCTs and indicate how performance
management tracking of SUIs will operate between SHA and PCT.

                                   APPENDIX 1
                        Definition of Adverse Incidents

Adverse Incident
An adverse incident is an unwanted, unplanned, or unexpected event or accident
that may or may not result in physical injury, loss or damage or the risk thereof. It
may be a single or multiple events caused by unsafe acts, unsafe conditions or

The definition includes incidents involving patients, clients, visitors, relatives, carers
and staff and including care management problems, theft, fraud, assault, personal
accidents involving staff and fire.

In order for an incident/accident to be reportable, it must arise out of or in
connection with a work activity whether being carried out on the Trust premises,
independent contractors’ premises or in a patient’s home.

A hazard is anything that has the potential to cause harm loss or damage e.g.
faulty equipment, torn carpets, most drugs, spillage of cleaning and disinfecting
solutions etc

A clinical incident is referred to as an adverse incident occurring in a clinical
setting; and is defined as an event or omission arising during clinical care and
causing physical or psychological injury to a patient or a service user and can
contain one or more of the following factors:

   Clinical decision making
   Clinical care related to poor or unexpected outcome
   Clinical management, treatment e.g. medicine incident
   Non availability of or inaccurate health records (please note it is a requirement
    that an incident form is completed for all such incidents.)
   Missed/incorrect or delayed diagnosis
   Failure to treat appropriately
   Drug errors
   Significant staff shortages
   Failure to act on results

The term 'clinician' is used in the broadest sense to cover medical, nursing,
therapies or other professional or technical groups, including support staff working
as part of the clinical team.

It is the responsibility of each clinical service/department head to identify specific
examples of clinical incidents and communicate these throughout the
service/department and to the Risk Manager. These definitions will be reviewed
regularly. This does not preclude the reporting of incidents that are not on the list.

In order to manage and investigate an adverse incident appropriately it may be
categorised according to their gravity into a:

   Near miss
   Minor adverse incident
   Serious untoward incident
   Major incident

Fuller details are given in Appendix 3 page 20- Risk Assessment Framework
(Grading and Categorising an Adverse Incident) of Part I - Adverse Incident
Reporting Procedure)

Near Miss
Near miss is a situation in which an event or omission does not result in actual
harm, loss or damage but might have produced unwanted or unexpected
consequences. These consequences could have been ranging from minor loss or
harm to catastrophic loss or harm.

Near misses are as important to record and investigate as those incidents where
actual harm was sustained. Near misses can highlight potential problems and allow
the organisation to remedy matters before actual harm.

For the purpose of reporting, a near miss must be treated as an actual incident and
reported by using the incident reporting form.

Within the severity grading currently used by the NPSA, ‘near misses’ are now split
into two categories rather than one and are referred to as:

• Prevented incidents, an example of which could be - a patient ring their GP
practice for a follow-up appointment to monitor Warfarin levels. An appointment
letter is sent, but would not have been if the patient had not rung.

• No harm incidents, an example of which could be - a patient is receiving
Warfarin as an outpatient, however the GP surgery fails to monitor clotting levels
according to protocol. The patient mentions this at a later date, and when they are
finally checked they are found to be within normal limits.

Minor Adverse Incident
Minor adverse incidents may be defined as incidents where minor harm, loss or
damage occurs but does not result in time off from work or disruption of
work/service. Such incidents would usually be green on the Risk Assessment

Examples of minor adverse incidents include:
 Physical or verbal aggression but resulting in no harm
 Fire alarms without actual fire

   Equipment problems without actual harm
   Insignificant harm to a patient
   Falls resulting in no injury

For detailed guidance, please see Appendix 2 “Grading an Adverse Incident and
Near Miss” in “Procedure for Reporting Adverse Incident & Near Miss”

Serious Untoward Incident (SUI)
A serious untoward incident (SUI) can be broadly described as when an accident
or incident involving a patient, member of staff, visitor on NHS property, contractor
or other person to whom the organisation owes a duty of care, occurs causing
significant loss or damage, serious injury or unexpected death. It includes
situations where:
 Serious damage occurs to NHS property e.g. through fire, criminal activity, etc.
 A major health risk occurs e.g. out break of notifiable diseases such as blood
    borne viruses (Hepatitis B&C etc) or radiation incidents.
 Unexpected death of a child, adult or elderly person
 Large scale theft or fraud
 Where litigation is expected
 A number of service users or staff are affected
 That attracts adverse media attention or has other ramifications for the PCT
    that may be disproportionate to the actual nature of the incident itself.
 A serious threat to the health of the community, disruption to the health service,
    or causes significant public concern.

For detailed guidance, please see Appendix 2 “Grading an Adverse Incident and
Near Miss” in “Procedure for Reporting Adverse Incident & Near Miss” –SUI is
likely to be graded brown or red.

Major Incident
A major incident is any event, which presents a serious threat to the health of the
community, disruption to the health service, or causes (or likely to cause) such
numbers or types of causality as to require special arrangements to be
implemented. The examples include Train crash, large outbreak of communicable
disease, chemical contamination and radioactive release.

A major adverse incident can also be categorised by using the Risk Assessment
Framework (Grading and Categorising an Adverse Incident) – A major incident is
likely to be graded red.

                                 APPENDIX 2
                         Roles and Responsibilities
All Staff Members
Staff members are responsible for:
 Making themselves aware of the incident reporting policy and procedure
 Reporting adverse incidents if they were involved, have witnessed or
 Ensuring they know how to complete the incident reporting form
 Familiarising themselves with the actions needed in case of adverse incidents
 Making themselves aware about where the Incident report books are kept
 Availing opportunities for training around incident reporting, management and
   other related issues

Chief Executive
In the event of a Serious Untoward Incident (SUI), RED incident or a Major
Incident, the Chief Executive must be notified who will then take the overall charge
for the SUI and ensure that:

   Initial (24 hours report) is received from the lead director
   Satisfactory immediate steps have been taken to minimise risks
   Necessary communication channels have been established
   Appoint a Chair for the Investigation panel
   Approve the Terms of reference and membership of the Investigation panel

For all “Red” incidents (SUIs), the Chief Executive may appoint the Chair of the
investigation panel or delegate the responsibility to any director.

Responsible Director/ Director on Call
In the event of a Serious Untoward Incident (SUI), RED incident or a Major Incident
the lead director (if out of hours, Director on call) will ensure that:

   The Chief Executive is informed of the incident
   Immediate remedial action/s taken by the most senior person on the scene are
   Appropriate arrangements are made to preserve the evidence
   Hazards are appropriately removed
   Security and safety of all individuals is achieved
   Any relevant health or other records are secured and kept in a safe and
    confidential environment. This should be done with the agreement of the
    consultant or senior practitioner. These records may be subsequently needed
    to be made available as part of the investigation process. Where they are
    needed for the continuing care of the patient; a duplicate set should be made
    up for this purpose.
   Ensure that equipment and other substances (e.g. vaccines) involved were

   Contemporaneous record of events is prepared in a chronological order and
    reported to the Chief Executive and the Director of Quality and Performance
    Improvement within 24 hours of the incidents (if weekend, on the next working

For all other grade of incidents (not SUIs), the directors must ensure that a
summary report is received at appropriate directorate meetings (Management or
Governance meetings).

The lead director /AD must ensure that they sign off the investigation reports for
moderate incidents.

The lead director must ensure that the recommendations from the investigation
reports for serious incidents are implemented and monitored.

Line Managers / Team Leaders / Senior Managers
It is the responsibility of each line manager/team leader to check:
 All details are correct
 Take all measures possible to minimise adverse incidents within his/her area
 Investigate all adverse incidents, in accordance with PCT investigation
 Take all necessary action to prevent re-occurrence
 Promote and encourage staff to report all adverse incidents
 Ensure incident form completed
 In line with the level of their responsibility and depending on the severity of
     incident, ensure that the recommendations are implemented

Senior Managers are also responsible for presenting the outcome of investigations/
recommendations in their Directorate Team Meetings or equivalent.

Occupational Health & Safety Manager
The Occupational Health and Safety Manager will be responsible for:
 Ensuring that on receipt of an incident report form related to health and safety,
   security or environmental issues, all interested parties are informed of the
   adverse incident
 Deciding on whether any further action is required over and above that already
   taken at department level e.g. RIDDOR Reportable, Medical Devices Agency
   (MDA) Reportable etc.
 Liaising with designated managers and senior managers on any actions
   required preventing re-occurrence, identifying causal factors and improvements
   to any procedures
 Monitoring and analysing health & safety incidents occurring within the PCT
   and notifying departments of emerging trends
 Providing summary reports to the Health & Safety Committee

   Ensure that Health and Safety Executive (HSE) are notified of any incident
    covered under the Reporting of Injuries, Diseases and Dangerous Occurrence
    Regulations 1995 (RIDDOR).
   Ensuring that the risk register is updated for Health & Safety risks
   Provide support to staff in notifying the Health & Safety and non-clinical

Risk Manager
The Risk Manager will be responsible for:
 Monitoring the investigation of all serious untoward incidents
 Monitoring all incidents graded red and reporting to the relevant committees
 Ensuring the risk register is updated
 Following an investigation, notifying potential claims to the NHSLA
 Reporting to Trust Board, Governance Committee and Management Team
▪ Liaising with the NPSA to ensure that relevant data about patient safety
   incidents is sent to them
▪ Ensuring that changes in national policy or legislation is reflected in the policy
▪ Notification and reporting to NHS London

Occupational Health
Managers must ensure that all staff members who remain off work for three
continuous weeks or more following an adverse event are referred to Occupational
Health prior to their return to work. For further details, reference should be made
to “Policy and Procedure for Managing Sickness Absence”.

Human Resources
It is the line manager’s responsibility to ensure that advice is sought from the
Human Resources department on any issues relating to employee’s entitlements
where sickness has resulted through an industrial accident.

                                      APPENDIX 3
                               Reports to Committees
Reports of incident investigations and trend analysis of incidents will be submitted
to the appropriate committees within the Trust as set out in the table below.

Committee            Report                           Frequency      Responsible
Board                Trends of all incidents          Quarterly      Risk Manager
Board Part 2         SUI opening reports              Quarterly      Risk Manager
Board Part 2         SUI closing reports              As necessary   Lead Director
Governance           Trends of all incidents          Quarterly      Risk Manager
Health & Safety      Trends for Health & Safety       Quarterly      Occupational Health &
Committee            incidents                                       Safety Manager
                     Specific investigation reports   As             Occupational Health &
                     for health and safety            appropriate    Safety Manager
                     incidents graded red
Management Team      Trends of all incidents          Quarterly      Risk Manager
                     Summary of investigation         As             Risk Manager
                     reports for all incidents        appropriate
                     graded red

These reporting arrangements will be reviewed to reflect any subsequent changes in governance
and reporting structures.


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