Procedure for Serious Incidents Policy

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					    PROCEDURE TO FOLLOW IN THE CASE OF A
       SERIOUS INCIDENT (OR NEAR MISS)


             BARNSLEY PRIMARY CARE TRUST




Author:                   Designation:                  Date:
S. Bentley                Director of Performance and
                          Quality                       March 2003
E. F. Richardson          Ass’t Director HR, Health &
                          Safety
Authorised By:            Designation:                  Date:

                          Lead Director

Review:      March 2004
Issue No:




                                                                Page 1 of 9
PROCEDURE TO FOLLOW IN THE CASE OF A SERIOUS INCIDENT (OR NEAR MISS)

1.   When an employee becomes aware that a serious incident has taken place it
     is their responsibility to report this immediately to his/her immediate manager
     or senior person on duty in the area in which the incident took place. Where
     this is not the senior manager responsible for the area where the incident took
     place, steps must be taken to notify him/her immediately. Out of hours contact
     can be made via the on call arrangements. An IR1 reporting form must be
     completed in all cases.

2.   The senior manager is responsible for notifying the line Director who will notify
     the Chief Executive and Director of Performance and Quality and for taking
     control of the immediate situation. Update reports to the Chief Executive and
     Director of Performance and Quality must be provided as necessary.

3.   In the event of a serious fire, or a serious non-clinical incident, the senior
     manager is responsible for notifying the Health & Safety Department as soon
     as practicable after the event. The Assistant Director of HR (Health & Safety)
     will be responsible for reporting fire incidents to the NHSE. The Assistant
     Director of Risk Management will be responsible for reporting medical device
     incidents to the Medical Devices Agency. The Responsible Person will be
     responsible for reporting RIDDOR incidents to the HSE.

4.   In the event of a serious Clinical/Care incident the senior manager is also
     responsible for ensuring that the Medical Director, the client’s Consultant
     and/or GP (if appropriate) and the Director of Nursing Services (if there is a
     nursing element) are informed.

5.   The senior person on duty must ensure that all information is recorded at the
     time of the incident including contemporaneous records of events as they
     unfold and decisions made. Also, client records must be secured (as
     appropriate), an FORMS report form must be completed and if necessary
     written statements must be obtained. He/she must also ensure that the scene
     is protected or all information and equipment involved is held centrally in a
     place of safety for access at a later time.

6.   The senior manager must immediately carry out (or ensure so) the statutory
     reporting to external agencies by phone if appropriate e.g. Police, Coroner,
     with the agreement of the Line Director or Nursing Director.

7.   The senior manager or Consultant must ensure that relatives know and clients
     are notified of the incident.

8.   Where media interest or a press release is contemplated clients and/or their
     relatives must be consulted. If the clients ability to give informed consent is in
     doubt the decision whether or not to inform relatives will rest with the medical
     staff. No information must be given to any outside agencies eg the press
     without the express agreement of the Chief Executive, Director of
     Performance and Quality or Corporate Secretary.



                                                                          Page 2 of 9
9.    All press statements and media briefings will be co-ordinated by the Corporate
      Secretary or other designated press officer.

10.   The Director of Performance and Quality is responsible for notifying details of
      the incident to the Strategic Health Authority, Regional Office, National Patient
      Safety Agency and PCT’s Legal Advisers as appropriate.

11.   If a serious incident report is required under the Mental Health Act it is the
      responsibility of the senior manager to report it accordingly.

12.   If it is necessary to contact clients on a wide scale, then a designated “hot line”
      will be set up. Additional staff may be required to man phones and processes
      will be set up to record calls received and advice given. This will be done in
      line with the PCT’s response to a major accident.

13.   If there is a major clinical incident this should be dealt with in line with the
      PCT’s response to a major accident.

14.   Where disciplinary action is contemplated the senior manager should appoint
      an investigating officer and instigate an immediate inquiry.

15.   The senior manager will also instigate an investigative multi-disciplinary
      meeting involving the relevant employees from the area in which the incident
      took place. The multi-disciplinary meeting will be chaired by the senior
      manager and will consider the incident and recommend any action or learning
      points. A report of the meeting must be forwarded to the Chief Executive with
      clear recommendations within 14 days of the incident.

16.   The Chief Executive on receipt of the report will discuss its contents with the
      Medical Director or Executive Committee Chair in order to establish whether
      the report should go to the Executive Committee’s complaints/incidents Sub
      Group for consideration or whether the Serious Incident Inquiry group should
      be convened. The PCT’s Serious Incident Inquiry Group consists of:-

             •   Non-Executive Director
             •   Medical Director or Executive Committee Chair
             •   Clinical member of the Executive Committee
             •   Nurse Director
             •   Director of Performance and Quality
             •   Internal/External expertise as required

      16.1   The group will be responsible for examining all information pertaining to
             the incident and as a result provide the PCT’s Executive Committee and
             Board with recommendations to ensure that a repeat of the incident
             does not occur. Recommendations will be based on:

             •   Root cause analysis of the incident;
             •   Any changes to policies or procedures;
             •   Any training needs;
             •   Any further expertise required;

                                                                            Page 3 of 9
             •    Any disciplinary action not already identified;
             •    Identification of any resource issues with financial details.

      16.2   Any anonymised report will be sent to the Executive Committee.

      16.3   The senior manager will be responsible for reviewing agreed actions
             and recommendations after 6 months. The Executive Committee will
             monitor this.

17.   Examples of ‘Serious Untoward Incident’

      17.1   The following list is not exhaustive and is intended as guidance only.

             a)      An element of judgement is inevitable but where any doubt
                     exists, the safest option will be to report the incident.

      17.2   Factors which might suggest a ‘serious untoward incident’ include:

             a)      suspicion of large-scale theft or fraud or any incident which might
                     give rise to serious criminal charges;

             b)      impending large scale litigation (including negligence claims);

             c)      repeated serious complaints about an employee or primary care
                     contractor;

             d)      suspicion of a serious error or errors by an employee or primary
                     care contractor which could give rise to public concern;

             e)      a serious breach of confidentiality;

             f)      a number of unexpected/unexplained deaths, including apparent
                     clusters of suicides of clients in receipt of psychiatric care;

             g)      the suicide of any person;

             h)      the accidental death of, or serious injury to, any individual (client,
                     staff or visitor) on NHS premises;

             i)      death or injury where foul play is suspected;

             j)      serious damage which occurs on NHS premises or any incident
                     which results in serious injury to any individual or serious
                     disruption to services;

             k)      absconsions by clients detained under the Mental Health Act
                     1983;

             l)      apparently trivial incidents which may have disproportionate
                     ramifications, including those which could attract media attention.

18.   Mental Health Act Commission Classification Of ‘Untoward Events’


                                                                              Page 4 of 9
18.1   Definition

       a)    An Untoward Event is ‘… A deviation from the pattern of ordinary
             communal living, such as might adversely affect the well being of
             clients’. Ashworth Inquiry Report (1992).

       b)    Untoward Events should be classified according to the
             seriousness of the outcome and in accordance with the system
             shown below

18.2   Class ‘A’ Incidents

       a)    These are incidents that result in death or cause such serious
             harm that they place the client’s life in jeopardy. They include,
             but are not limited to, homicide, attempted homicide, sudden and
             unexpected death and suicide.

18.3   Class ‘B’ Incidents

       a)    These are incidents that are not life threatening, but which
             acutely jeopardise the well being of the client. They include, but
             are not limited to, allegations of client abuse, or neglect, sexual
             assaults, racial assaults, attempted suicide, aggravated assaults,
             unexplained injuries and serious errors of medication. (They
             may amount to Class C incidents).

18.4   Class ‘C’ Incidents

       a)    These are incidents which seriously affect, or have the potential
             to affect seriously, the health or the psychological well-being of
             the individuals involved. They include, but are not limited to,
             errors of medication (which may amount to Class B incidents),
             sexual improprieties, sexual, racial and gender harassment.
             Accidental injuries, assaults and act of deliberate self-harm may
             amount to either Class C or Class D incidents depending on the
             severity of the outcome.

18.5   Class ‘D’ Incidents

       a)    These are incidents which result in no injury, or in only very
             minor injury and do not involve any blameworthiness on the part
             of any member of staff. They include, but are not limited to, minor
             accident injury, fights between clients without weapons and acts
             of deliberate self-harm.

18.6   Class ‘E’ Incidents

       a)    Any other untoward occurrence.



                                                                    Page 5 of 9
19.      Untoward Incidents Reported To The Strategic Executive Information
         System (STEIS)

         19.1   As from 1 April 2002 STEIS became the Department of Health’s data
                collection tool for untoward incidents.

         19.2   Untoward incidents which should be reported to STEIS can be defined
                as:-

                a)    An event or omission arising during clinical care and causing
                      physical or psychological injury to a client.

                b)    An incident that did not lead to harm but could have done – near
                      miss.

                c)    Any other incident that is a potential or actual newsworthy event.

         19.3   Information about an incident must be reported via STEIS as soon as
                possible and certainly within two days of the incident occurring.

         19.4   There is a defined format for submission of information to STEIS.

         19.5   The following information will therefore be required (see attached
                proforma):

•     Date, time, location of incident.
•     Care sector/clinical area.
•     Details of the client involved – type, gender, date of birth, ethnic group and
      whether the client is under the care of Mental Health Services.
•     Details of the incident itself.
•     Immediate action taken
•     Whether the incident has been reported to external organisations such as the
      coroner, police etc.
•     Apparent outcome, likelihood of recurrence, most likely consequences, potential
      risk to other clients.
•     Lessons learnt. (This information may not be available at time of reporting
      incident).
•     Details of any or potential media interest.
•     The full name of reporting office together with job title and date.

         19.6   The South Yorkshire Health Authority will chase up outstanding
                information, particularly “lessons learnt” on a weekly basis.

         19.7   Details of untoward incidents should be reported to the Director of
                Performance and Quality, or the Principal Administrator, Risk
                Management. Information can be given either verbally in the first
                instance and then followed up as soon as possible in writing via email
                or typed report.




                                                                            Page 6 of 9
                                                                    STEIS Proforma

                              UNTOWARD INCIDENT

         Information required for Strategic Executive Information System
                                      (STEIS)

When and Where Details


Date of Incident:                           Time of Incident:


Site of Incident:                           Location of Incident:


Who

Care Sector:                                Type of Client:


Clinical Area:                              Gender:


Date of Birth:                              Ethnic Group:


What Happened


Type of Incident:

Actual/Near Miss:


Brief description of what happened:

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………


                                                                        Page 7 of 9
Immediate action taken:

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………


Reported externally to:


Details of any Internal Enquiry Reports:

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………


Lessons learnt from the incident:

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………


Details of any or potential media interest.
Relatives reaction to incident (if known):

…………………………………………………………………………………………………

…………………………………………………………………………………………………

…………………………………………………………………………………………………




                                              Page 8 of 9
FORMS Form:           ID Number:


Date of completion:



Reported by:          Name:    ………………………………………………………………

Job Title: ………………………………………………………………

Date:     ………………………………………………………………


Signature: ……………………………………………………………




                                                  Page 9 of 9

				
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