Replaces (if appropriate):
Policies applied by legacy Causeway, United and Homefirst Trusts
Policy Author/Team: Type of document:
Liam O’Kane Corporate
Assistant Director of Finance
(Financial Accounting and Financial
Approved by: Date Policy disseminated by Policy
Northern Trust Senior Management
Team 1 December 2008
28 October 2008
NHSCT MISSION STATEMENT
To provide for all the quality of services we would expect for our families
Northern Health and Social Care Trust
One of the basic principles of public sector organisations is the proper use of public
funds. It is therefore important that all those who work in the public sector are aware of
the risk of, and means of enforcing, the rules against fraud and other illegal acts
involving dishonesty or damage to property. For simplicity, all such offences are
hereafter referred to as fraud, except where the context indicates otherwise. This
document sets out the Trust’s policy and response plan for detected and suspected
The Trust has procedures in place that reduce the likelihood of fraud occurring. These
include Standing Orders, Standing Financial Instructions, documented procedures and a
system of internal control and risk assessment. In addition, we try to make sure that a
risk and fraud awareness culture exists in the Trust.
This document is intended to guide and help those directors and officers who find
themselves having to deal with suspected cases of theft, fraud or corruption. It gives a
framework for a response and advice and information on various aspects and
implications of an investigation. This document is not intended to provide guidance on
prevention of fraud.
Standards of business conduct
Circular HSS (GEN1) 1/95 dated March 1995 gave guidance to HPSS employers and
staff in maintaining strict ethical standards in the conduct of the HPSS business. It
stated the guiding principle that public sector bodies, including the HPSS, must be
impartial, honest and open in the conduct of their business and that staff are expected to
make sure that the interests of patients and clients remain paramount.
The Trust policy
The Trust is absolutely committed to maintaining an honest, open and well-intentioned
atmosphere within the Trust. It is therefore also committed to the elimination of any
fraud within the Trust, and to the rigorous investigation of any such cases.
The Trust wishes to encourage anyone having reasonable suspicions of fraud to report
them. It is the Trust’s policy that no employee will suffer in any way as a result of
reporting reasonably held suspicions.
For this purpose, reasonably held suspicions shall mean any suspicion other than those
which are raised maliciously and found to be groundless.
Roles and responsibilities
Responsibility for investigating fraud has been delegated to the Director of Finance.
He/she shall also be responsible for informing third parties such as the Department of
Health, Social Services and Public Safety, the Head of Internal Audit and the police,
where appropriate. The Director of Finance shall inform the Chief Executive of all cases
of fraud or suspected fraud.
Further details of roles and responsibilities are included in the Trust’s Fraud Response
Plan which is attached.
Fraud Response Log
The Director of Finance will arrange for the maintenance of a Fraud Response Log. All
reported suspicions will be recorded in the log including those dismissed as minor or
otherwise not investigated. The log will also contain details of actions taken and
The log will be available for review by Internal Audit and/or Audit Committee.
The Trust is committed to the principles of Section 75 of the Northern Ireland Act and the
Human Rights Act.
Any queries on this policy should be made to the Director of Finance.
This policy will be reviewed by the Director of Finance every two years.
Northern Health and Social Care Trust
Fraud Response Plan
This procedure note sets out the responsibilities of officers and actions to be followed for
all occasions when a case of fraud is suspected within the Trust.
Fraud is defined as "the intentional distortion of financial statements or other records
by persons internal or external to the organisation carried out to conceal the
misappropriation of assets or otherwise for gain".
The scope of suspected fraud might range from internal incidents (e.g. involving petty
cash or employee claims for travelling and incidental expenses) to circumstances
affecting third parties. A list of the most common types of fraud is included at Appendix
1 as an aid to recognising fraud in its various guises.
It also incorporates the following:
Theft, which is defined as "dishonestly appropriating property belonging to another with
the intention of permanently depriving them".
Corruption, which is defined as "the offering, soliciting or accepting of an inducement or
reward which may influence the action of any person".
Discovery of fraud
In accordance with paragraph 26.2.2 (Losses and Special Payments) of the Trust' s
Standing Financial Instructions, any employee or officer discovering or suspecting a loss
of any kind must either immediately inform their Head of Department, who must
immediately inform the Chief Executive, their Director and the Director of Finance or
inform an officer charged with responsibility for responding to concerns involving loss.
This officer will then appropriately inform the Director of Finance and/or Chief Executive.
As fraud constitutes or has the potential to constitute loss to the Trust, these reporting
requirements apply to cases of fraud.
An initial suspicion should be treated with the utmost caution and discretion since
apparently suspicious circumstances may turn out to have a reasonable explanation or
even have a malicious source. In the event of a malicious source being proven, the
Trust reserves the right to initiate disciplinary proceedings as appropriate.
The following appendices detail the responsibilities of staff in dealing with fraud:
• Head of Department Appendix 2
• Director of Finance Appendix 3
• Lead Officer Appendix 4
• Head of Internal Audit Appendix 5
• Disciplinary Authority Appendix 6
Where any officer mentioned above is under suspicion, the responsibilities will revert to
the next most senior officer.
EXAMPLES OF COMMON METHODS AND TYPES OF FRAUD
• Cash stolen
• Over claiming expenses
• Payment for work not performed
• Delayed terminations from payroll
• False persons on payroll
• Working elsewhere while on sick leave
• Cheques made out to false persons
• Altering amounts and details on documents
• Theft of official purchasing authorities such as order books
• Transactions (expenditure/receipts/deposits) recorded for incorrect sums
• False official identification used
• Damaging or destroying documentation
• Using copies of records and receipts
• Altering stock records
• Forged endorsements
• Collusive bidding
• Writing off recoverable assets or debts
• Unauthorised transactions
• Selling information
• Altering sales records
• Unrecorded transactions
• Supplies received but not recorded
• Using imaging and desktop publishing technology to produce apparent
• Skimming odd pence and rounding
• Running a private business with official assets
• Using facsimile signatures
• False compensation and insurance claims
• Stealing of discounts
• Selling waste and scrap
Responsibilities of the Head of Department
The Head of Department must:
• Immediately inform their Director and the Director of Finance of any suspected
fraud. Where staff are involved, the Head of Department must also comply with the
Trust' Disciplinary Procedure.
• Secure any documents, premises, assets or equipment, such as computers, which
may be interfered with; before doing so he/she must liaise with appropriate Human
Resources Business Partner.
• Arrange access to such documents, premises, assets or equipment as may be
required by investigating officers;
• Co-operate with any investigations being carried out.
Responsibilities of Director of Finance
• Action this Response Plan and react to the suspected fraud by:
- Liaising directly with HR Assistant Director Employee Relations where an
employee is under suspicion to determine the application of the Trust'
- Informing the Head of Internal Audit;
- Informing the Chief Executive;
- Updating the Fraud Response Log.
• Arrange for a preliminary investigation to be carried out to review findings and decide
A) To discontinue the investigation, as suspicions were not confirmed
B) To continue with a full internal investigation as suspicions were confirmed
(and certify to that effect), and to;
1. Agree the objectives and terms of reference of the investigation as
recommended by the Lead Officer, who will be appointed by the
Director in the affected area.
2. Agree the resources necessary for the investigation as recommended
by the Lead Officer.
3. Maintain contact with the Lead Officer and Disciplinary Authority, if
appropriate, throughout any investigation.
Review the likely outcome, based on the Lead Officer' Initial Report,
and arrange for the necessary action to be carried out.
5. Keep the Chief Executive and relevant Directors updated on cases as
6. Inform the Counter Fraud Policy Unit of DHSSPS and PSNI, giving a
named point of contact in the affected department.
7. Advise the Chief Executive and Director of Human Resources, as
appropriate, if criminal action is to be taken against a member of staff.
8. Liaise with Corporate Communications Department on any media
9. Ensure the Audit Committee is apprised twice yearly of on-going fraud
Responsibilities of Lead Officer
A Lead Officer will be nominated by the Director with responsibility for the service area in
which the suspected fraud has occurred.
The Lead Officer will:
• Organise the investigation on behalf of the Director of Finance, proposing the
objectives and terms of reference and keeping him / her informed of significant
• Ensure that evidence is collected in a discreet manner and that proper working
papers are maintained.
• Be the point of contact for liaison with the PSNI, and any other appropriate bodies.
• Prepare an Initial Report on the progress and findings of the investigation for the
Director of Finance and Disciplinary Authority, if necessary.
• Ensure the Initial Report includes a debriefing note identifying system weaknesses
and lessons to be learnt, together with an Action Plan with named responsibilities
and completion dates.
• Ensure the Initial Report quantifies the loss to the Trust
• Request assistance from Internal Audit and / or the Finance Directorate as required.
Responsibilities of Head of Internal Audit
The Head of Internal Audit will
• Undertake such investigation as directed by the Lead Officer, ensuring that
collection of evidence is in accordance with the Police and Criminal Evidence Act
• Keep the Lead Officer advised of progress during the investigation.
• Submit a report to the Lead Officer detailing the action taken and the resultant
• Consider any Action Plan and debriefing notes prepared by the Lead Officer and
advise of any corporate governance implications.
Responsibilities of the Disciplinary Authority
The Disciplinary Authority will:
• Determine the course of action required on receipt of the Initial Report;
• Make sure that Trust disciplinary procedures are followed in all cases reported to it;
• Determine whether or not there is a prima facie case for disciplinary action;
• Decide upon suspensions and disciplinary action where appropriate;
• Keep the Chief Executive and Director of Finance advised of progress with any
disciplinary action or the reason why it was deemed that disciplinary action was