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Serious Untoward Incidents Protocol For Plymouths Drug and

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Serious Untoward Incidents Protocol For Plymouths Drug and

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									            Plymouth Teaching Primary Care Trust

        Serious Untoward Incidents Protocol
                       For
       Plymouth’s Drug and Alcohol Services

                          Version No 1:3




Notice to staff using a paper copy of this guidance

The policies and procedures page of Healthnet holds the most recent and
approved version of this guidance. Staff must ensure they are using the most
recent guidance.




Authors/Editor                Chirs Wagner: tPCT Risk Manager, and
                              Russ Hayton: DAAT Clinical and Service
                              Governance Manager

Access ID Number              143
Reader Information

 Type of Formal Paper          Protocol
 Category                      Corporate
 Title                         Serious Untoward Incidents Protocol for Plymouth’s Drug
                               and Alcohol Services v1:3
 Document Purpose              This document has been produced to ensure a common
 and Description               approach to Serious Untoward Incidents across the
                               City’s locally commissioned Drug and Alcohol Services,
                               which also complies with the standards established by
                               Plymouth tPCT.
 Author(s)/Editor(s)           Chris Wagner and Russ Hayton
 Ratification Date and         14th June 2006, by the Governance Committee.
 Group                         Reviewed October 2008 and extended.
 Publication Date              October 2008
 Review Date                   1 October 2009
 Disposal Date                 See Retention and Disposal Schedule
 Job Title of Person           TPCT Risk Manager and
 Responsible for               DAAT Clinical Governance Service Manager
 Review
 Target Audience               Service Directors/Chief Executives of locally
                               commissioned drug and alcohol services for
                               dissemination and implementation to all staff within their
                               organisation
 Circulation List              Electronic: Via Healthnet
                                            Via PCT website (subject to Freedom of
                                            information exemptions)
                               Written:     Upon request to the Public Information
                                            Service on ℡ 01752 272511

                               Please note this document can be made available in
                               other formats if required please contact the Public
                               Information Service on ℡ (01752) 272511
 Patient and Public            The policy has been published to Plymouth User Group
 Involvement                   (Sub. Misuse) and anonymised reported incidents will be
                               published to them, or discussed with them on request.
 References                    Plymouth teaching PCT Serious Untoward Incident
                               Policy 2005.
 Supersedes                    Serious Untoward Incidents Protocol for Plymouth’s Drug
 Document                      and Alcohol Services v1
 Contact Details               Russ Hayton
                               Clinical & Service Governance Manager
                               Plymouth Drug and Alcohol Team
                               The Public Dispensary
                               18 Catherine Street
                               PLYMOUTH
                               PL1 2AD
                               ℡01752 315778
                               Russ.Hayton@phdu.nhs.uk

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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
Document Version Control

 Version         Details      Date                Author of               Description of
 Number            e.g.                            Change             Changes and Reason for
              Updated or                                                     Change
               full review
     1        New          April 2006        Russ Hayton:            New document.
              document                       Clinical
                                             Governance
                                             Manager and
                                             Chris Wagner:
                                             Risk Manager
    1:1       Updated         12/05/2006     Jade Brelsford:         Updated to comply with
                                             Deputy Manager,         corporate standards.
                                             Public Information
                                             Service
    1:2       Updated         16/08/06       Russ Hayton:            Updated with minor change
                                             Clinical                to procedure relating to
                                             Governance              copying of casefiles.
                                             Manager,
                                             Plymouth DAAT
    1:3       Reviewed        28/10/08       R. Hayton               Reviewed, no changes
                                                                     made.




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
Contents

Not required for short documents

 Section        Content                                                              Page No

      1         Introduction                                                              5

      2         Responsibilities                                                          6

      3         Immediate Investigation and Follow Up                                     9

      4         Serious Untoward Incidents Involving Children                            11

      5         Serious Untoward Incidents – Internal Review                             11

      6         Internal Review Team – Terms of Reference                                11

      7         Outcome of Internal Review                                               13

      8         Communications                                                           14

      9         Other Agencies                                                           14

 Figure 1       Incident Investigation Flowchart – Key Steps                             15

 Appendix Immediate Notification of a Serious Incident                                   16
    A

 Appendix Serious Untoward Incident Checklist                                            19
    B

 Appendix Serious Untoward Incident Feedback Report                                      21
    C




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
Plymouth Teaching Primary Care Trust

Serious Untoward Incident Protocol for Plymouth’s Drug
and Alcohol Service

1.     Introduction
1.1    This protocol is derived from Plymouth’s teaching Primary Care Trust (tPCT)
       protocol for Serious Untoward Incidents, adapted for use by local Drug and
       Alcohol Services, as part of the governance arrangements established by
       Plymouth’s Drug and Alcohol Action Team (DAAT). The protocol is additional
       to each service’s internal Incident Reporting Protocol, and will form part of the
       regular portfolio of reports by DAAT to the Strategic Health Authority and tPCT
       Chief Executive and Board, via the tPCT Clinical & Corporate Governance
       Committee, as required by the National Treatment Agency (NTA) and the
       Healthcare Commission.

1.2    The DAAT, as the commissioning agency for local drug & alcohol services,
       and provider agencies, are keen to learn from incidents and will conduct
       internal reviews when indicated, with the assistance of the tPCT governance
       team, to ensure that any changes in practice and procedures required are
       implemented.

1.3    As the Strategic Health Authority (SHA) draft guidance states:

         “There is no single definition of a serious untoward incident but, in general
         terms, is something out of the ordinary or unexpected ….”

1.4    Whilst it is not possible to cover all types of incidents, examples of situations
       for which this protocol is appropriate include:

       1.4.1 Any incident involving serious harm or potentially serious harm to a
             service user, service users or the public…

       1.4.2 Any incident involving national or extensive local media interest…

       1.4.3 Any incident involving serious implications for service user or staff
             safety…

       1.4.4 Any incident involving serious compromises or allegations of serious
             compromises…

       1.4.5 The above list is not exhaustive …… the underlying request is……. ‘No
             surprises’

1.5    Where directors or managers believe an incident does fall within one of the
       above categories they should discuss this with the DAAT’s Clinical & Service
       Governance Manager, or if not available, the tPCT’s Risk Manager, to agree a
       way forward.
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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
         DAAT office:                                                 01752 515478
         tPCT Risk Manager/tPCT Governance Office:                    01752 314169

1.6    The overriding emphasis of all incident reporting and investigation is to learn
       from these events, not to attribute individual blame or to punish. This approach
       will enable services to concentrate on learning and improving systems and
       processes to manage risk more effectively.


2.       Responsibilities

2.1      The DAAT is responsible for:

         2.1.1 Establishing this protocol across all locally commissioned drug and
               alcohol services, and ensuring annual review.

         2.1.2 Providing advice and assistance to Service Directors or Deputies,
               senior practitioners, and managers regarding the application of the
               procedure, in collaboration with the tPCT Governance Team.

         2.1.3 Assisting the tPCT’s Chief executive with reporting requirements to the
               Strategic Health Authority (SHA), and other external stakeholders, and
               providing regular reports to the PCT Board via the tPCT Clinical &
               Corporate Governance Committee, and to the Healthcare
               Commission, in collaboration with the tPCT Governance Team.

         2.1.4 Advising the Chief Executive of the tPCT, with notification to the
               Board, regarding incidents that may attract public attention, in
               collaboration with the tPCT Governance Team and relevant Service
               Director.

         2.1.5 Monitoring the application of the procedure and advising the Chief
               Executive and Board of the tPCT of any required changes.

         2.1.6 Co-ordinating the reviews, investigations and independent inquiries
               into the incident(s) and liasing with the SHA, to feedback any lessons
               learned to Service Director (or Deputy), in collaboration with the tPCT
               Governance team

2.2      Service Director (or Deputy) and managers are responsible for:

         2.2.1 Ensuring that the DAAT office is formally notified of all serious
               untoward incidents, within one working day. (Tel: 01752 515478)

         2.2.2 Ensuring this procedure is implemented and followed effectively within
               their service(s) by all staff, volunteers, and trainees.

         2.2.3 Ensuring all staff of the service are aware of this protocol and their
               responsibilities within it.


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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
         2.2.4 Ensuring sufficient numbers of staff receive incident investigation
               training.

         2.2.5 Advising the Chair of the service’s Board of Trustees regarding
               incidents that are of concern or may attract public attention.

         2.2.6 Monitoring the application of the procedure and advising the Chair of
               the service’s Board of Trustees any difficulties.

2.3      Senior Managers and Team Leaders are responsible for:

         2.3.1 Ensuring this policy is followed.

         2.3.2 Contacting their Service Director (or Deputy), as soon as practicable
               during that working day, depending on the circumstances of the
               incident.

         2.3.3 In the event of a homicide, suicide or other event that may cause
               public interest, the Service Director (or Deputy) and the DAAT team
               must be informed within one working day. The Clinical & Service
               Governance Manager of the DAAT, and the Service Director (or
               Deputy) can assist in defining such incidents and, in conjunction with
               the Chief Executive of the tPCT, will identify persons to form the
               Internal Review Team, which includes external representation to
               ensure service objectivity and independence.

         2.3.4 The Senior Manager is responsible for undertaking the immediate
               investigation and must assume responsibility for the retention and
               collection of all records, statements and other documents pertaining to
               the incident. All relevant original records must be sent without delay to
               the DAAT office for copying along with the original incident form. The
               original documents will be returned to the service as quickly as
               possible. Original documents may be requested for the first review.

         2.3.5 Ensuring the immediate well being of service user(s), staff or others
               including contacting, as necessary, the emergency services.

         2.3.6    Making sure a contemporaneous record of events is maintained and,
                 at the earliest opportunity on that working day, preparing an internal
                 accident/incident form.

         2.3.7 Assisting in any critical incident investigation.

         2.3.8 Ensuring that lessons learned are identified and applied to their
               service.




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
2.4      Staff at service level will normally be those who first become aware of a
         serious untoward incident. These staff will be responsible for:

         2.4.1 Reporting the incident immediately to their Manager, or Service
               Director (or Deputy).

         2.4.2 Responding to the immediate needs to those harmed as a result of the
               incident, and taking steps to prevent further harm.

         2.4.3 Preserving the scene and retaining equipment, records and other
               materials relevant to the incident, whenever possible.

         2.4.4 Co-operation with detailed investigations may be required, using root
               cause analysis tools and techniques.

         2.4.5 Ensuring changes to practice are introduced as a result of lessons
               learned.

2.5      The Senior Manager will make available the following key information to
         the Service Director (or Deputy) and DAAT team:

         2.5.1 Description of incident

         2.5.2 Where incident occurred

         2.5.3 Details of service users affected by incident – name, age and any
               relevant diagnosis, or presenting problems (including any known risk
               issues).

         2.5.4 Details of staff affected by incident – name, position and next of kin,
               injuries

         2.5.5 Action already taken, including contacts made and times

         2.5.6 Information already given to service users/families/staff

         2.5.7 Whereabouts of key staff

         2.5.8 Any concerns for the service that are known at this point in time.

         2.5.9 Whether this incident may be of interest to the media.

         2.5.10 In any case of suicide, or homicide, or other serious untoward incident,
                the person contacted will appraise the DAAT’s Clinical & Service
                Governance Manager or tPCT Risk Manager of the incident as soon
                as reasonably practicable.

         2.5.11 Complete Appendix A Immediate Notification Of A Serious
                Untoward Incident within 1 working day of the incident being


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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
                 identified. This form should be sent simultaneously by e-mail to
                 the 3 addresses below:


               1. Victoria.West@phdu.nhs.uk

               2. Russ.Hayton@phdu.nhs.uk

               3. seriousuntowardincident@pcs-tr.swest.nhs.uk (for information)


         2.5.12 On receipt of this e-mail, the Risk Manager of the tPCT, and the DAAT
                will arrange notification to the SHA as required.

         2.5.13 A checklist is available at Appendix B

2.6      Information to Service users and Public

         2.6.1 The Service Director (or Deputy) will need to decide, following
               discussion with the DAAT officers and the tPCT Chief Executive and
               Communications Manager, the level of information that may be made
               available to service users, relatives and the public who, in turn, will be
               briefed as agreed.

2.7      Approaches from the Media

         2.7.1 Service users or relatives and staff should, if possible, be briefed
               before the media. Any direct approaches from the media should be
               dealt with courteously along the following lines:

         2.7.2 “I am sorry I am not in a position to comment at the present time but if
               you would like further information please contact our Service Director
               (or Deputy) (and offer a telephone number).”


3.       Immediate Investigation and Follow Up (within 2 working
         days)

3. 1     For each serious untoward incident, there will be an investigation and rapid
         review as soon as reasonably practicable, involving relevant practitioners and
         staff, and usually led by the Service Director (or Deputy). The investigation
         team will usually include the following:

           •   Service Director (or Deputy)
           •   DAAT Clinical & Service Governance Manager
           •   Team manager from the area of incident
           •   Member of the Specialist Medical Team, and/or relevant GP
                (if clinical issues are involved)
           •   tPCT Risk Manager, or member of the tPCT Governance Team
               (if appropriate e.g. Mental Health Services involvement)
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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
         This will include situations where the reported death comes via another
         source some time after the incident, for example, the Coroner.

         3.1.2 This review must include:

                 •   Description of incident
                 •   Details of service user(s) affected by incidents (name- age- any
                     diagnosis or relevant problems, and any known risk)
                 •   Details of staff involved and where based
                 •   Debrief if incident involved staff on duty at the time
                 •   Action already taken including dates and times and any actions
                     agreed with Service Director (or Deputy) and DAAT Clinical &
                     Service governance Manager
                 •   Short background history of service user
                 •   Chronology of events of incident, including lead up and
                     consequence
                 •   View of staff involved (this is also the opportunity to debrief the
                     staff when the incident is reported after the event - for example the
                     death of a client in the community)

                 Outcomes
                 • Possible concerns for service area
                 • Any obvious learning points
                 • Recommendations

         3.1.3 This information must be provided in the form of a report and sent to
               the DAAT within 3 working days. This information will provide the
               background to the full internal review team if required.

         3.1.4 An anonymised (summary) report must also be sent to the tPCT
               Clinical & Corporate Governance Committee by the DAAT for shared
               learning.

3.2      Secure Information/Equipment

         3.2.1 In all cases where the SUI process is followed, ALL relevant health
               and social care records must be secured and, when appropriate, a
               copy made and sent to the DAAT Office, unless the Coroner’s officer
               or police have taken these away in the course of their investigation. In
               this case copies must have been made and retained by the Service,
               with a FULL copy sent to the DAAT office. Any items of equipment
               involved in the incident must be retained.

3.3      Debriefing of Staff

         3.3.1 Whilst investigation of the incident is on-going, staff should be
               regularly appraised of the situation. The appropriate Senior Manager
               should be available with the Service Director (or Deputy) to debrief
               staff. Counselling may be necessary for some staff, after the incident.
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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
4.       Serious Untoward Incidents Involving Children
4.1      Where abuse or neglect are known or suspected to be a factor in the death
         or serious injury to a child, the Local Safeguarding Children Board (LSCB)
         will consider the need to undertake a serious case review, as defined under
         Part 8 of “Working Together”. The tPCT Chief Executive will be informed by
         the Chair of the LSCB Serious Case Review Committee that a Serious Case
         Review is to be undertaken. The named nurse for child protection will have
         the lead responsibility within the tPCT to undertake the agency’s individual
         management review and action plan, which will be reported back to LSCB.
         Although the process, after an incident involving a child, will be tracked
         through the Risk Management Group, the reporting will follow part 8, as
         defined in the Multi-agency Child Protection Procedures January 2005,
         pages 92 to 99.


5.       Serious Untoward Incidents – Internal Review
5.1      Where a SUI is reported, the Service Director (or Deputy) and DAAT, in
         conjunction with the tPCT Risk Management Department, will decide whether
         a formal review is required, and will take other advice, as necessary.

5.2      Where other organisations are involved, the tPCT Chief Executive and
         relevant Service Director (or Deputy) will ensure access to relevant
         practitioners, managers, records and any other relevant material, as
         sensitively and collaboratively as circumstances permit.

5.3      Internal Reviews should be established promptly – although, where court
         proceedings in relation to the incident have started – or are likely to – legal
         advice should be sought with a view to ensuring that the review does not
         prejudice those proceedings. Internal Reviews will also need to take account
         of any coroner’s inquest – although awaiting the outcome is not an option.


6.       Internal Review Team – Terms of Reference
6.1      The review is commissioned by the tPCT Chief Executive, on behalf of any
         other participating organisations.

6.2      The Review team will include 3 appropriately experienced senior
         professionals, with at least one being an appropriately qualified and
         experienced drugs and alcohol specialist, ensuring appropriate medical input
         with regard to any clinical issues.

6.3      The nominated Chair will have demonstrable independence from the service
         in which the incident arose.

6.4      At least one of the 3 must not be employed by the agency in which the
         incident took place.

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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
6.5      The review should:

         6.5.1 Be established within two weeks of the incident
         6.5.2 Begin work within four weeks of the incident
         6.5.3 Report to the tPCT Chief Executive, as ‘Commissioner’ not later than
               ten weeks after the incident

6.6      The Review team can co-opt others, with agreement from the
         ‘Commissioner’, if additional professional or other experience is required.

6.7      The Review Team will agree administrative support with the DAAT.

6.8      The Review Team will ensure all notes are photocopied and a complete set
         given to the relevant practitioners involved in the case when a serious
         incident is being investigated

6.9      The Review Team will agree a process for communicating progress to
         relevant audiences (e.g. people receiving services involved and their families
         and managers) with the Commissioner.

6.10     In all serious incident investigations, all reports are shared in full with the
         practitioners who were responsible for providing care

6.11     The review will use Route Cause Analysis tools to focus on:

         6.11.1 Any assessment of the incident already conducted by the service. (Ref
                3.1)

         6.11.2 A review of the adequacy of that assessment – and the extent to
                which any recommendations for action have been complied with.

         6.11.3 The quality and appropriateness of health, social, and other care
                provided, and any risk assessment(s) undertaken.

         6.11.4 The extent to which care plans were documented, discussed and
                agreed, communicated, co-ordinated and complied with by the
                person(s) involved in the Incident.

         6.11.5 The adequacy of care monitoring by the responsible medical officer,
                care co-ordinator, keyworker etc. as appropriate.

         6.11.6 The exercise of professional judgement by those involved in the care
                delivered.

         6.11.7 The extent to which any relevant strategic obligations were complied
                with.

         6.11.8 The appropriateness of education, training and CPD available to, and
                taken up by, those involved.

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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
         6.11.9 A review of the multi disciplinary and/or inter agency working and
                communication, with partner organisations – where applicable.

         6.11.10Any identifiable reason for suggesting that transparently separate
         disciplinary processes; be conducted.

         6.11.11Any other issues that arise during the review – as agreed by the
               ‘Commissioner’.


7.       Outcome of the Internal Review
7.1      The Review chair will provide the Commissioner (tPCT Chief Executive) and
         the relevant Service Director with a Report, within the timescale agreed at the
         commencement of the Review. The Report should be structured to provide
         an Outline of the Process, Findings of the Review and Recommendations.

7.2      The Commissioner will share the Report with Chief Executive’s/Directors of
         other organisations (‘co-commissioners’) as applicable and will discuss the
         Report with the tPCT Head of Service Governance, DAAT officers, the
         Service Governance Leads Group (Substance Misuse), and others as
         appropriate i.e. the Specialist medical Team.

7.3      Following acceptance of the Report, based on the feedback from
         Commissioners and the tPCT Head of Service Governance, the
         Commissioner and relevant Service Director will make arrangements to
         share the Report with:

         7.3.1 The managers and practitioners of the service involved.

         7.3.2 The Boards of Trustees of the relevant service providers

         7.3.3 The relevant people using the service involved, and their families

         7.3.4 Other organisations, including the SHA or NTA, as necessary.

7.4      The relevant Service Director (or Deputy) will ensure an Action Plan is
         developed, to address Findings and Recommendations from the Report,
         within 4 weeks of receipt.

7.5      The Report and Action Plan, suitably anonymised, will be submitted to the
         tPCT Clinical & Corporate Governance Committee. Updates on the Action
         Plan will form part of the regular reporting cycle to that committee by DAAT
         until all actions are concluded and embedded.

7.6      Receipt of the anonymised Report at the tPCT C & C Governance Committee
         will constitute a requirement on other committee members to study the
         Findings, Recommendations and lessons learned – with the intention of
         taking any action identified as necessary within the services they represent.
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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
7.7    The full Report and Action Plan will be sent, on a confidential basis, to the
       SHA Chief Executive and Chief Executives/Directors of other organisations, as
       appropriate. Where the incident has resulted in the death of a child (under 18
       years of age), the ACPC will send the full report to The Social Services
       inspectorate. Consent would be needed from all agencies involved to disclose
       this report outside the formal ACPC process.

7.8    On completion of the whole process, A Serious Untoward Incident
       Feedback Report (Appendix C) will be circulated to staff involved in the
       incident, in order to relay any findings.


8.     Communications
8.1    At all stages of the investigation, from the time the SUI is first reported to the
       final report, consideration should be given to the communications process,
       both internal and external. The tPCT Chief Executive and the DAAT, assisted
       by the PCT Communications Manager, the relevant Service Director (or
       Deputy), and the investigation team will agree on the level of information to be
       communicated, the recipients, and the method of conveyance.

8.2    In cases where there has been an Independent Inquiry, the tPCT Chief
       Executive and the DAAT, assisted by the PCT Communications Manager, and
       the relevant Service Director (or Deputy), will produce a briefing strategy.


9.     Other Agencies

9.1    Consideration should be given to other agencies that may need to be involved
       in any investigation, namely:

             Other local D & A Services              National Treatment Agency
             Strategic Health Authority                Medicines and Healthcare Regulatory Agency
             Police                                    Department of Health
             Coroner                                   Health and Safety Executive
             Social Services                           Environmental Agency




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
    Figure 1: Key Steps in Managing a Serious Untoward Incident


                                                                                      Key
                                                                                    Document
               Serious Untoward Incident Occurs                                       Ref.


   Staff contact their manager as soon as possible and gather                         Sec 2.4
                         key information.


   Manager informs Service Director (or Deputy), collects
   records, statements and incident form and sends 3
   simultaneous emails of Appendix A to:                                              Sec 2.3

   1. Victoria.West@phdu.nhs.uk                                                       Sec 2.5

   2. Russ.Hayton@phdu.nhs.uk

   3. seriousuntowardincident@pcs-tr.swest.nhs.uk


    Service Director appraises DAAT of situation. DAAT liaises
            with the tPCT Chief Executive, as required.


  Rapid review of incident by:

          • Head of Service/Service Director (or Deputy)
          • DAAT Clinical & Service Governance Manager
          • Team manager from the area of incident
          • tPCT Risk Manager, or member of the tPCT                                  Sec 3
              Governance Team (if appropriate)


    Outcome reported to the DAAT team, which will decide if a
     formal internal or external review is required, with advice
      from the tPCT Risk Management Dept., as necessary.



        Formal review team report to tPCT Chief Executive,
         relevant Service Director, and DAAT for onward
                     distribution and learning                                        Sec 7



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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
                                         Appendix A

           Immediate Notification of Serious Untoward Incident
Sect 2.5 of the Protocol for Serious untoward incidents refers. This document should
be completed after discussion with the appropriate Service Director (or Deputy) and,
if required, the DAAT’s Clinical & Service Governance Manager. This document
should then be sent simultaneously by e-mail to the following 3 addresses
within 1 working day of the incident:

               1. Victoria.West@phdu.nhs.uk

               2. Russ.Hayton@phdu.nhs.uk

               3. seriousuntowardincident@pcs-tr.swest.nhs.uk




Today’s Date: ………………………Date and time of incident:
………………………………

SUI Ref No………………………………………
(To be completed by DAAT office and disseminated to all relevant parties)

Completed by:

Name:                                       Designation:

Date and Time                               Name of Service:
completed:

Service user/ Carer/Staff
Name:

DoB (if known):

Occupation:
(If Member of Staff)
Staff, Service user or
Carer? :
Name of area/building
where incident took place:
Residential or community
setting
Responsible Medical
Officer


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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
Care Co-ordinator or
Keyworker:
Service user ID number:

Diagnosis, relevant
problems and known Risk
Issues:
(Including drug and/or alcohol
problems)

When last seen by staff:

Currently on caseload                Yes/No

Established Care Plan?               Yes/no

Date of last Risk
Assessment:
If risks identified currently,
is there a Risk Management
plan in place?
Name of Person initially
informed of incident:
Date and time informed:

Incident/Accident form               Yes/No
completed. (send copy to
DAAT with SUI Notification)
Police involvement:                  Yes/No

Date, time and exact place
of incident:


Nature of incident:
Fatal/Near Miss - Please
describe and include any
injuries sustained.


Other involved:
(relatives/carers/clients)

Staff involved:


Equipment Involved:



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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
What led to the incident:



Immediate action taken:



Was support and
information offered to
relatives/carers and by
whom. Please Describe:



Who undertook to support
staff, and were they offered
the opportunity to discuss
the incident? If not offered
support please specify why
Date and venue:

Are there any follow up              Yes/No – describe
arrangements?

Have arrangements been               Yes/No – describe.
made to support staff not
on duty at time of incident?
Are there any immediate              Yes/No – describe.
concerns regarding care.

Records have been secured
and are being held at:

Arrangements for Further
Reporting within 3 Working
Days
(discuss with Service
Director, or Deputy, prior to e-
mailing)

Internal or External
Investigation Required
(discuss with Service
Director, or Deputy, prior to e-
mailing)


                                              END

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                                         Appendix B

              Serious Untoward Incident Process - Check List
This checklist assumes that, in the event of a SUI occurring, staff have taken
emergency steps as required, informed Police and other services where necessary,
and the Service Director (or Deputy) and DAAT team have been contacted as per
SUI Policy section 2.5

                             Action Required                                         SUI
                                                                                    Policy     Done
                                                                                     Ref.
 SUI Notification form completed by manager within 1 (one)
 working day of incident and e-mailed to tPCT– DAAT office                           2.2
 (both addresses) and ‘Serious Untoward Incidents’ address

 DAAT office, in collaboration with tPCT Risk Manager (or                            2.1
 Deputy), to notify SHA, if required.



 2. Immediately following notification of a SUI, the manager                         2.3.4
 ensures they examine all relevant records ASAP and makes
 immediate arrangements for safe storage of all related
 documents.

 3. Line manager ensures relevant staff complete
 contemporaneous notes (and internal incident form) to assist in                     2.3.4
 production of written statement and these are signed and dated.
 Where appropriate, a copy of all relevant documents will be sent                    2.3.6
 to DAAT office (including the internal incident form).
                                                                                     3.2.1

 4. Service Director (or Deputy) produces written report giving
 details of incident – to tPCT Director of Clin & Corporate                          3.1.3
 Governance and DAAT office within 3 working days


 5. Service Director (or Deputy) ensures a Post SUI Staff Support                    3.3
 meeting has been offered.

 6. Service Director and DAAT, in conjunction with tPCT Risk                         5.1
 Management Dept., review initial report to identify if full
 internal/external review is required.

 7. If internal review required, follow terms of reference                           6.0



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 8. Internal review report                                                           7.0




 10. Review action plans, implementation and report progress.                        7.5




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
                                            Appendix C

                  Serious Untoward Incident Feedback Report

Incident Code
List initials for identification in the integrated Clinical Governance Action Plan (IGAP)

Type of incident (i.e. medication error /violence)


Name of service where incident occurred


Antecedents


Incident


Consequence of incident (i.e. any damage done)



Stage in the care process at which the event occurred (assessment, during treatment
or post discharge)



List the problems or issues that were considered to be of greatest significance,
fundamental issues / or identified as root causes (i.e. those directly impacting on the
outcome of course of this event)

Areas to consider:
Service User/Individuals involved
Task
Equipment
Team & Social
Working conditions
Communication




Other Factors identified during incident review as areas for improvement to
consider




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    List the Improvement Strategies or recommendations made for addressing the
                                       issues:




Positive issues/practice identified from review / areas of good practice to share
with organisation:




What changes are expected in local specialist services?




What changes will individual staff be expected to make?




How these changes will be audited?




Review date for Recommendations:




This form has been developed out of the six steps to Root Cause Analysis from
the Consequence Organisation providing training on RCA and the NHS
National Patient Safety Agency outline for reporting.

This RCA reporting form has been modified using feedback from Plymouth
teaching Primary Care Trust Staff in the Mental Health Clinical Governance
Group in order to provide a vehicle to feedback to staff about outcomes,
learning and changes required in practice.

KH/IJ Nov 2005.




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Serious Untoward Incidents Protocol for Plymouth’s Drug and Alcohol Services v1:3
The Lead Director approves this document and any attached
appendices.


Signed: -      ………………………………………………………………………

Date: -        ………………………………………………………………………




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