NHS Trust by chenmeixiu

VIEWS: 14 PAGES: 95

									                                              Incident Reporting and Management
Document name:                                (including Serious Untoward Incidents)



Document type:                                Policy and procedures



Staff group to whom it applies:               All staff



Distribution:                                 Trust-wide



How to access:                                Intranet



Issue date:                                   May 2010



Next review:                                  Nov 2011



Version:                                      4



Approved by:                                  Executive Management Team



Developed by:                                 Helen Roberts
                                              (Incident Management Support Team)


Director leads:                               Director of Nursing, Compliance and
                                              Innovation


Contact for advice:                           Helen Roberts and Linda Hollingworth
                                              risk@swyt.nhs.uk




Page 1 of 95 Incident Reporting and Management - Version 4 (17/5/10)
Section                                      Contents                              Page

  1        Introduction                                                             5

  2        Purpose and Scope of the Policy                                          6

  3        Definitions (see also Appendix X)                                        7

  4        Duties, roles and responsibilities                                       7

  4.1      Trust Board, Chief Executive and Directors                               7

  4.2      Committees                                                               8

  4.3      Executive Management Team                                                9

  4.4      Corporate Incident Management Support Team                               9

  4.5      Communication Team                                                       9

  4.6      Role of Specialist Advisers                                              10

  4.7      Service managers                                                         10

  4.8      Manager responsibilities                                                 10

  4.9      All staff (including contractors, agency and temporary staff)            11

  5        Policy Development, Approval and Review process                          12

  5.1      Approval of the document                                                 12

  5.2      Consultation and communication with stakeholders                         12

  5.3      Equality Impact Assessment                                               12

  5.4      Policy Review process                                                    13

  5.5      Version control                                                          13

  6        Incident Management, Reporting and Recording Procedures                  13

  6.1      What should be reported and recorded as an incident?                     14

  6.2      Managing an incident – immediate actions and next steps                  17

  6.3      Grading the severity of Incidents using the Risk Grading Matrix          18

  6.4      Reporting and Recording incidents                                        18

  6.5      Management Fact Finding Report                                           21

  7        Reporting and Managing Serious Untoward Incidents Procedure
                                                                                    22
           (incidents graded Red)



 Incident Reporting and Management – Version 4 (17/5/10)            Page 2 of 95
  7.1        Reporting Requirements                                                     22

  7.2        Serious untoward incidents – who to inform and when                        23

  7.3        Serious Untoward Incident Action checklists – overview                     23
             a)     Responsibilities of Person in Charge of Unit, Team or Department
                    following a Serious Incident
             b)     Responsibilities of responsible Manager (including On Call
                    Manager) following a Serious Incident
             c)     Out of Hours arrangements
             d)     Responsibilities of the Incident Management Support Team
                    following a Serious Incident

   8         Communication and Notification                                             29

  8.1        Patient/relative/visitor/contractor communication, information & support   29

  8.2        Support for staff                                                          30

  8.3        Process by which to raise concerns                                         30

   9         External notification and communication                                    31

             a)     Working with partner agencies and in joint teams
             b)     External reporting of incidents
             c)     Post incident Communication
             d)     Statutory Bodies
             e)     External and shared Policies, Procedures and Protocols

   10        Managing inquiries from the media or the public                            33

             a)     Media Attention
             b)     Hotline and control room arrangements
             c)     Freedom of Information Act 2000
             d)     Inquires from people directly affected by an incident

   11        Investigating and analysing incidents, complaints and claims to learn      34
             from experience

   12        Dissemination and Implementation                                           35

   13        Process for monitoring compliance with this document                       36

   14        Associated documentation                                                   36

   15        References                                                                 37

Appendices

   A         Equality Impact Assessment Tool                                            39


  Incident Reporting and Management – Version 4 (17/5/10)             Page 3 of 95
 B        Checklist for the Review and Approval of Procedural Document                    41

 C        Version Control Sheet                                                           43

 D        Guidance on Completing an Incident Report Form (IRF)                            44

 E        Incident Report Forms: guidance for managers                                    45

 F        Datix and datixweb – electronic risk management database                        49

 G        Risk Grading Matrix: Incident severity grading                                  50

 H        Examples of reportable incidents                                                53

  I       Examples of Serious Untoward Incidents (Red incidents)                          58

 J        Flowchart for reporting Amber and Red incidents                                 58

 K        Management Fact Find Report                                                     60

 L        Externally reportable incidents                                                 65

 M        External and internal stakeholder: communicating and involving                  71
          stakeholders in relation to adverse events

 N        Risk Assessment Form (generic)                                                  73

 O        Action plan format                                                              75

 P        Reporting Deaths flowchart                                                      76

 Q        Incident record keeping and record retention                                    77

 R        Control Rooms and Hotline Arrangements                                          81

 S        Guidelines for staff on producing written statements for internal reviews and   83
          external inquiries following an adverse incident

 T        Contacts for advice and support                                                 86

 U        Information governance and data loss incidents                                  87

 V        D of H checklist for Information Governance (IG) incidents                      90
          CQC registration and notification requirements - guidance for NHS
 W                                                                                        91
          providers (Health and Social Care Act 2008)
 X        Definitions                                                                     94




Incident Reporting and Management – Version 4 (17/5/10)           Page 4 of 95
1.0 Introduction
This document describes the Trust‟s commitment to a safety culture through the
effective management of adverse incidents, including serious untoward incidents.

The NHS is committed to providing a safer service for both staff and patients. This
priority has emerged because of real concerns about the things that go wrong for
patients in the NHS, and the need to ensure that the NHS and individual organisations
learn from experience.

This policy is supported by the Trust‟s Risk Management Strategy and related risk
management policies and procedures. Together these ensure that the Trust identifies
and makes improvements as a result of adverse events in order to improve safety for
service users, staff, visitors and contractors, and operates within a just, honest and
open culture. Effective incident management and an incident reporting culture are
integral to this process.

Being open and a just culture

A safety culture has to be open, honest and fair. This means that:

          Staff are open about any incidents and near misses and feel able to discuss
           them with colleagues and managers
          Staff and the Trust are accountable for their actions
          The Trust is open with service users, their relatives and carers, partner
           agencies and the public when things have gone wrong, and will explain
           what lessons have been learned

Just culture
The Trust aims to work within an open honest and just culture in which staff can be
assured that they will be treated fairly and with openness and honesty when they
report adverse incidents or mistakes.

Being open
Service users, relatives, carers, staff and partner agencies need to know when
something has gone wrong and what the Trust is going to do to minimise harm and
prevent recurrence. Service users, carers, relatives and staff can expect to be
provided with appropriate information and support following any patient safety incident
by the Trust. See the Trust‟s Being Open Policy for further guidance.

This document should be used in conjunction with other related Trust documents
listed in section 13 and in particular related documents on Investigating and analysing
incidents, complaints and claims to learn from experience, Being open, and
Supporting staff following adverse events.




 Incident Reporting and Management – Version 4 (17/5/10)      Page 5 of 95
2.0 Purpose and Scope of the Policy
 2.1     Purpose
The purpose of this document is to provide information and guidance to support all
staff in identifying, reporting and managing incidents and near misses, including
serious untoward incidents.

There are clear stages to overall incident management, whatever the grade or severity
of the incident. Detailed guidance is provided in Sections 6 and 7 and covers:

   i. Identifying an incident – ensuring staff are able to recognise and incident and
        know who to contact if they are unsure. See Section 6 and Appendix H.
   ii. Managing the incident - immediate actions to take to ensure the safety and
        well being of those directly or indirectly involved, or to prevent immediate
        recurrence. See section 6
   iii. Grading the severity of Incidents using the Risk Grading Matrix- to ensure
        the incident is responded to appropriately. See Section 6 and Appendix G
   iv. Reporting, recording and communication regarding the incident – See
        section 6
   v. Reporting and managing Serious Untoward Incidents (Red incidents) –
        See Section 7

   The separate Trust document on Investigating and analysing incidents, complaints
   and claims to learn from experience policy (available on the intranet) sets out how
   the Trust ensures that incidents are investigated to retrospectively establish what
   happened, the fundamental reason/s why it happened and what will prevent
   recurrence.

 2.2     This document applies to:
      Staff of any grades and role, in any department, service or area of the Trust.
      Incidents that occur on any of the Trust‟s premises, including those that involve
       service users, employees, visitors or contractors.
      Incidents involving Trust employees or service users that occur in any other
       setting, when a Trust employee is carrying out his/her Trust duties.
      Incidents that occur as a result of the care and treatment provided by the Trust
      Serious Untoward Incidents (SUI) such as a serious injury or a suspected
       suicide or homicide while a service user is receiving care and treatment from
       the Trust or has been in contact with Trust services in the previous 6 months.
       See Appendix I for a list of examples of potential SUIs.
      Incidents that have actually occurred and those that were a „near miss‟.

Mental health and learning disability services in the Trust are provided on an
integrated basis with the three Local Authorities Social Services Departments of
Calderdale, Kirklees and Wakefield. This joint working is an accepted and respected
part of service delivery within the Trust. As members of integrated services staff from
these local authorities will play an active role in delivering this policy and will make key
decisions as part of the process. Where appropriate this may also apply to complaints
and claims relating to the Trust or to one of the Local Authorities.

 Incident Reporting and Management – Version 4 (17/5/10)         Page 6 of 95
 2.3     Rational for development
This document has been developed to reflect national requirements and guidance
(see section 8) including An Organisation with a Memory (Department of Health,
2000), Seven Steps to Patient Safety (National Patient Safety Agency 2003) and
Being Open (NPSA, 2009). (See References in section 14).

3.0 Definitions
There are a range of different terms and definitions related to risk management,
incidents and adverse events, and patient safety. Key definitions of the terms used in
the context of this and related documents are listed in Appendix X.

4.0 Duties, roles and responsibilities
 4.1     Trust Board, Chief Executive and Directors
The Trust Board is ultimately responsible for ensuring that this policy is effectively
implemented. This includes scrutinising the management of incidents within the
organisation, ensuring that incident management processes are effective, compliant
with legal, statutory and national requirements and support safety, learning, just and
open cultures within the Trust. The Trust Board will:
       Receive assurance regarding effective incident management and
        implementation of incident management policies and procedures from relevant
        Committees
       Be made aware of new serious untoward incidents and the actions being taken
        to effectively manage the incident
       Be made aware of any particular concerns and issues in relation to trends or
        peaks in incidents and of the actions the Trust is taking to address these
       Be made aware of new independent inquiry reports and of the actions being
        taken to implement the recommendations

In addition, identified individuals and groups will provide assurance to the Trust Board
as outlined below.

Executive directors
The chief executive is ultimately responsible for:
       Service user, staff and visitors health and safety
       Ensuring compliance with legal, statutory and national requirements in relation
        to health and safety, including effective incident management
       Ensuring that incident management processes are effective and are supporting
        robust safety, learning, just and open cultures within the Trust.
       Ensuring the Trust board, chair and non executive directors receive relevant
        information regarding incidents and incident management including serious
        untoward incidents.
       Ensuring that partner agencies and other stakeholders are informed of
        incidents as necessary



 Incident Reporting and Management – Version 4 (17/5/10)      Page 7 of 95
The Director responsible for incident management has accountability and
responsibility for the development, implementation and review of this policy on behalf
of the chief executive, and will ensure that appropriate information reports,
performance reports, and updates are available to appropriate individuals and groups
to provide assurance of the processes to the Trust board.

All Executive Directors are responsible for:
       Implementation of this policy in their areas of responsibility.
       The management and analysis of information and implementation of relevant
        learning in their areas of responsibility.
       Ensuring that any organisational risks are forwarded to the Executive
        management team for consideration for inclusion in the appropriate risk
        register.
       Working together when necessary to address areas where a shared risk or
        learning action has been identified.

 4.2     Committees
The Terms of Reference for Trust Committees can be found on the intranet.

The Committee with responsibility for incident management has responsibility for
scrutinising the systems for effective incident reporting and management is
responsible for providing assurance to the Trust Board for:
       Continuous development, approval and dissemination of this policy
       Scrutiny of the effective implementation of this policy

This Committee will receive regular incident management information reports and
updates provided from a range of sources. This will include information about overall
incident management, the management of particular incident types and the
management of and learning from serious untoward incidents including independent
inquiries. Reports will provide evidence that:
       Incidents are reported, managed and investigated effectively and that remedial
        action is taken in a timely way
       Information about incidents (and complaints and claims), based on individual
        and aggregated analysis, is made available and is systematically reviewed to
        identify themes, trends and issues of concern
       Information from incidents is used to inform learning including:
          o effective implementation of action plans
          o necessary changes are made to improve the safety and quality of Trust
              services
          o key learning is shared appropriately with relevant partner agencies
       The Trust is open with and supportive of service users and carers involved in
        incidents and complaints
       The Trust supports staff involved in traumatic/stressful adverse events.

Other Committees have a role in providing assurance of effective incident
management and learning to the Trust Board for areas specific to their remit, through
scrutiny of incident management information and updates provided by directors with
an identified area of responsibility, such as the Mental Health Act Committee.

 Incident Reporting and Management – Version 4 (17/5/10)     Page 8 of 95
 4.3     Executive Management Team
The Executive Management Team will receive regular information management
reports (individual and aggregated) for adverse incidents to enable the group to
monitor and performance manage incidents, and ensure that:
       This policy is being effectively implemented
       Any trends or issues of concern are being analysed and investigated
       Resulting learning and action plans are effectively implemented
       Organisational risks are identified and considered for inclusion in the
        organisational risk register
       Incident management policies and procedures including any amendments are
        approved and ratified

 4.4     Incident Management Support Team (IMST)
The Incident Management Support Team manages systems and processes which
support incident reporting and management. This includes:
       Managing the Trust‟s electronic risk management system (Datix)
       Monitoring and supporting incident reporting and recording
       Monitoring and auditing the data quality of incidents entered on Datix
       Monitoring and auditing incident grading to ensure that incidents are graded
        equitably.
       Monitoring the Serious Untoward Incident management
       Maintaining internal recording systems associated with incidents, including
        keeping Datix and filing systems up to date.
       Providing regular incident management information reports for the Trust groups
        and Committees.
       Providing other incident management information reports on request to other
        services and groups.
       Ensuring external reporting requirements are met eg to the National Patient
        Safety Agency, Strategic Health Authority and Primary Care Trust. (see
        Appendix M – list of external and internal stakeholders)
       Providing feedback on learning from incidents to services and staff
       Reviewing and develop relevant policies and procedures as required to ensure
        they are up-to-date and reflect current national policy and best practice.

 4.5     Communication Team
The Trust's Communication Team will:
       Inform and liaise with the communication team at Yorkshire and the Humber
        Strategic Health Authority and PCTs regarding incidents which are likely to
        attract media attention
       Manage media enquiries as appropriate. These will usually relate to Serious
        Untoward Incidents. (Every effort must be made to ensure that the service user
        and relatives/carers are informed of relevant information prior to the media.)
       If there is a need to issue a press statement in relation to an incident, this may
        be done in collaboration with another NHS organisation or partner agency.


 Incident Reporting and Management – Version 4 (17/5/10)        Page 9 of 95
 4.6     Role of Specialist Advisers
Specialist advisers provide advice and support to staff relating to their particular area
of responsibility and expertise across the Trust, including appropriate incident
management. They have access to Datix to enable and support them to:
       Review and monitor relevant incidents on Datix
       Respond to individual incidents to offer advice and support
       Ensure file notes are maintained
       Analyse incident patterns and trends
       Review the findings of incident investigation and analysis to identify learning
        and actions to prevent recurrence
       Implement actions to share the learning and improve services
       Ensure compliance with legislation
       Day to day implementation of policy and related procedures
       Provide incident management information to the relevant director and Trust
        group as required
       Reporting certain incidents to external agencies in conjunction with service
        managers

 4.7     Service managers
All senior service managers are responsible for the effective implementation of this
policy and procedure within their service. This will include ensuring:
       Policy dissemination and implementation; all relevant mental health and
        learning disabilities practitioners are aware of the policy and how it is
        implemented at local/team level
       Staff are competent to report and managing incidents (including serious
        untoward incidents) in accordance with relevant policies
       Where an area of risk is identified which cannot be immediately removed, that
        risk reduction measures are taken to control the risk, and that where
        appropriate:
            o These are included on the service risk register
            o Organisational risks are highlighted to the responsible director for
                consideration by the Executive Management Team for placement on the
                organisational risk register

 4.8     Manager responsibilities
Managers at all levels in the organisation are responsible for ensuring:

Policies, procedures and training:
   Staff are aware of this and other related policies and procedures and how to
     access them for reference.
   Staff access appropriate training/support for completing Incident Report Forms

Incident management:
   Incidents are managed to ensure the immediate safety and well being of those
     involved.

 Incident Reporting and Management – Version 4 (17/5/10)        Page 10 of 95
         Support and information was/is offered to those affected directly or indirectly by
          an incident – service users, carers, visitors, staff or others.
         Witness statements are taken as required. (see Appendix S)
         All incidents and accidents are correctly recorded on a Trust Incident Report
          Form (electronic or paper). They are also responsible for ensuring that paper
          records relating to incidents are transferred and stored safely.
         All completed Incident Report Forms (electronic or paper) are reviewed and
          approved, to verify that the incident grade and risk assessment are correct and
          that appropriate action has been taken.
         Ensure that a book of paper Incident Report Forms is available in the event that
          Datixweb is unavailable, so that data about an incident is logged at the time.
          Managers should ensure the information is entered onto Datixweb as soon as
          possible after the system is restored.
         All serious incidents are reported on the next working day to a senior manager or
          responsible director and the Incident Management Support Team (who will
          inform the Chief Executive‟s office).
         Liaise with the Health and Safety Manager regarding any member of staff who is
          unable to perform their normal job for more than three days as a result of an
          accident or incident at work.
         Liaise with the Named Nurse for Safeguarding Children where there is any
          concern about the welfare of a child.
         Follow the Vulnerable Adults procedure where the incident involves any
          allegation or suspicion of abuse of an adult in our care
         Liaise with Human Resources where there are any concerns about staff
          capability, competence or behaviour.
         Report any potential claims to the Legal Support Team according to the Policy
          and Procedure for Managing Claims.
         Comply with external incident reporting requirements

Learning from Experience:
   Incidents in area of responsibility are investigated according to the severity of the
     incident, to identify what happened and why
   Incident information is regularly reviewed and analysed to identify any patterns
     or trends that need to be investigated
   Necessary actions and changes are implemented based on the findings of
     incident investigations and reviews
   Feedback from the review of an incident is provided to those staff involved
   Issues for learning are brought to the attention of the other relevant colleagues,
     services, the Incident Management Support Team and / or the relevant Trust
     Specialist Adviser for sharing more widely across the Trust.

 4.9        All staff (includes contractors, agency and temporary staff)

          It is your legal duty to report an incident or near miss as soon as it is
           reasonably practicable after the incident.
          Ensure you are familiar with this and other related policies and procedures.
          Ensure that when an incident has occurred, the immediate safety and welfare
           of all those involved or affected, directly and indirectly is acted upon, and that
           they take any necessary actions to prevent harm or further harm.


 Incident Reporting and Management – Version 4 (17/5/10)            Page 11 of 95
      Report all incidents immediately to the person in charge of the team,
       department or building.
      Ensure that an electronic or paper Trust Incident Report Form (IRF) is
       completed for all incidents you are involved in or witness (for details on how to
       do this, see Section 6 and Appendix D (also see Whistle-blowing Policy).
      Staff members should ask their manager for feedback on what happened as a
       result of reporting the incident
      Inform your manager of any period of sickness absence, or if you are unable to
       perform your normal job, for more than three days resulting from an accident or
       incident at work
      Follow the Vulnerable Adults procedure where the incident involves any
       allegation or suspicion of abuse of an adult in our care
      Liaise with the Named Nurse for Safeguarding Children where there is any
       concern about the welfare of a child
      Liaise with other specialist advisers as necessary – see Appendix T
      Volunteers, students, work experience placement etc should report incidents to
       their supervisor, who is responsible for ensuring an incident report form is
       completed in conjunction with the individual concerned.
      Ensure all breaches in confidentiality and other information governance issues
       are reported as incidents and that advice is sought from the healthcare records
       and information governance manager.

5.0 Policy development, approval and review process
 5.1     Approval of the document
This policy has been approved by the Executive Management Team in accordance
with the Trust‟s policy for the development, approval and dissemination of policy and
procedural documents. Prior to approval the checklist for the review and approval of
procedural document has been completed (Appendix B). The Director of Nursing,
Compliance and Innovation is responsible for the development and review of this
policy.

 5.2     Consultation and communication with stakeholders
In developing this policy a range of stakeholders were identified and consulted.

                Stakeholder                               Level of involvement
Executive directors                                 Consultation dissemination and
                                                    implementation
Assistant directors and senior managers             Consultation dissemination and
                                                    implementation
Specialist advisers                                 Consultation and dissemination
Corporate incident, complaints and claims           Consultation and implementation
management teams
Health and safety group                             Consultation

 5.3     Equality Impact Assessment
The Trust is committed to providing services that meet the diverse needs of our
service users, population and workforce. An equality impact assessment has been
completed by the policy authors and approved by the EMT as part of the policy
approval process in accordance with Trust policy (See Appendix A).
 Incident Reporting and Management – Version 4 (17/5/10)           Page 12 of 95
Although no specific equality issues were identified in relation to implementing this
policy, staff involved in incidents need to be sensitive to any equality and diversity
issues when reporting and managing incidents.

 5.4     Policy review process
This document will be reviewed in line with the Trust‟s policy for the development,
approval and dissemination of policy and procedural documents. It will be reviewed to
ensure that it is up-to-date and reflects recognised best practice, and be re-issued on
or before the review date identified on the front cover. All amendments will be
approved in accordance with Trust policy. (See Appendix B)

 5.5     Version control
The front cover indicates the version, date of issue and review date of this document.
The most recent version will be available on the Trust intranet. Previous versions will
be archived in accordance with Trust policy.

6.0 Incident management, reporting and recording
This section provides detailed guidance on the incident management processes the
Trust requires staff to follow to report and manage incidents (including Serious
Untoward Incidents). This process is closely linked with the procedural document on
Investigating and analysing incidents, complaints and claims to learn from experience.

The following stages apply to incident management, whatever the grade or severity of
the incident:
a)     Identifying incidents – the Trust actively encourages and supports staff to
       report all incidents that occur on any of the Trust‟s premises, or in carrying out
       their Trust duties, including providing care in any other setting. To ensure this
       can take place, staff need to be able to recognise an incident or near miss and
       to ensure it can be managed and reported appropriately. More detailed
       guidance on what incidents should be reported is provided in Section 6.1 and in
       Appendix H
b)     Managing the incident: immediate action to ensure the safety and well being
       of those directly or indirectly involved, or to prevent immediate recurrence.
       More detailed information about managing incidents is provided in Section 6.2
c)     Grading the severity of Incidents using the Risk Grading Matrix
       Incidents that occur within the Trust will have different levels severity and
       impact. Not all incidents need to be investigated or responded to with the same
       depth or extent. To enable us to understand the severity and priority of an
       incident all incidents are graded in line with the Risk Grading Matrix developed
       by the Trust (Appendix G). Grading incidents enables us to:
         •   Understand the priority and level of response and investigation that is
             needed. The severity (or risk category) of the incident or near miss will
             determine the level of investigation and analysis that is required.
         •   Take into account a range of risk factors including outcome and the
             potential for the incident to lead to a complaint or claim
         •   Analyse and compare the severity of the incidents to recognise and learn
             from trends or patterns in the adverse events that are being reported.
 Incident Reporting and Management – Version 4 (17/5/10)        Page 13 of 95
d)         Reporting, recording and communication regarding the incident:
            • Informing appropriate managers of an incident in a timely way
            • Recording information about the incident and how it has been managed,
               which will include giving the incident a severity grading
            • Initially communicating with and supporting service users, carers, relatives
               and staff appropriately. All actions taken should be recorded.
            • Identifying if an incident may lead to a complaint or claim.

           More detailed information about reporting, recording and communicating
           incidents is provided in Section 6.4. Specific guidance on how to manage and
           report any serious incidents is in Section 7, and includes a series of action
           checklists for staff to follow.
e)         Investigating and analysing: ensuring that incidents are investigated to
           retrospectively establish what happened, the fundamental reason/s why it
           happened and what will prevent recurrence. This could include:
             • Review or full investigation (using Root Cause Analysis) of an individual
                incident – dependent on severity and the potential for learning;
             • Investigation of a cluster of incidents where a concern or potential for
                learning is identified
f)         Learning from experience:
            • Ensuring that the findings of any incident investigations, review or analysis
               are acted on to improve services by developing and implementing action
               plans to ensure that systems and services are changed and improved to
               prevent recurrence.
            • Using qualitative and quantitative data analysis from incidents, complaints
               and claims to highlight any trends which may be occurring and uncover
               any further need for intervention.
            • Ensuring that learning is shared appropriately across services - both in the
               area where the incident occurred and more widely across the
               organisation.

More detailed information about investigating, analyzing and learning from incidents is
provided in the investigating and analysing incidents, complaints and claims to learn
from experience procedural document.

     6.1    What should be reported and recorded as an incident?
a)         Introduction
An incident is an unintended and/or unexpected event or a circumstance that actually
did lead to, or could have led to, harm, loss or damage to a service user, a member of
staff, a visitor/contractor or to property (see definitions in Appendix X).

The Trust actively encourages and supports staff to report all incidents that occur on
any of the Trust‟s premises, or in carrying out their Trust duties, including providing
care in any other setting. This is to enable the Trust to understand what may be going
wrong and where, so that action can be taken to avoid this happening again and
improve patient and staff safety.

For this system to be most effective, the Trust requires staff to report and record all
incidents and near misses of any description on the Trust's Incident Report Form
 Incident Reporting and Management – Version 4 (17/5/10)         Page 14 of 95
(electronic or paper).. Responsibility for reporting and recording incidents rests with
all staff involved, independent of their seniority or professional group.

The following are examples of some of the main types of incidents that should be
reported. (See also Appendix H and I). Any incident or situation that gives rise for
concern should be reported. If in any doubt about whether something should be
reported or not, staff will discuss the situation with their line manager or contact the
Incident Management Support Team or the relevant Trust Specialist Advisor for advice
and support (see Appendix T for contact details).

b)          Main incident Types (actual incidents, prevented incidents and near
            misses)
          Health and Safety (including accidents, fire and security incidents)
          Missing/absent service user
          Care pathway/clinical incidents (including incidents relating to admission,
           discharge, transfer, communication)
          Child Protection incidents
          Violence and Aggression incidents
          Information governance incidents (eg confidentiality breach, health record issue,
           IT incident). See Appendices U and V.
          Self Harm incidents
          Legislation and Policy e.g. MHA, Trust Policies, illegal acts
          Death of service users (including suicide)
          Medication incidents
          Other incidents

c)          Setting incident thresholds for frequent challenging behaviour
In some clinical situations staff find it difficult to know when to record certain events or
behaviours as an incident. For example, if an individual service user has a frequent
pattern of behaviour such as self harming, verbal aggression or challenging behaviour,
which could be seen as the normal presentation of their condition either permanently
or at a particular time in their illness.

It is impossible to give a definitive guide for recording these incidents, but the following
process is suggested to ensure consistent and informed incident recording:
         o In most cases all these should be recorded as incidents
         o Where a service user presents with behaviour which is in some way a potential
           risk to themselves or others, but it is so frequent that the team do not consider it
           to be an incident, or reporting it as an incident is for some reason
           therapeutically contra-indicated, the care team (Multi-Disciplinary Team) will
           review this presentation on an individual basis.
         o The review will agree a threshold above which an incident will be recorded eg
           by identifying what is considered to be the person‟s „normal‟ presentation at that
           point in time and agreeing at what point the behaviour is beyond that
           „threshold‟.
         o This review process and decision should be recorded in the individuals care
           plan and records.
         o The agreement will be reviewed regularly (at least at each care review meeting)
           and amended as necessary

 Incident Reporting and Management – Version 4 (17/5/10)            Page 15 of 95
     o In taking this decision, the team need to consider carefully whether their
       decision is influenced by:
            a. an „acquired immunity‟ to what are in fact incidents
            b. avoiding completing Incident Report Forms.
     o It is strongly recommended that any incidents involving actual violence towards
       others is recorded as an incident, and that anything which is RIDDOR
       reportable must be reported as an incident. (See guidance in Appendix L.)
     o It should be noted that if a decision is taken not to record behaviours as an
       incident it will not be taken into account in any analysis of incidents.

Care should be taken not to put service users, staff, children or others at risk by
using this approach; staff should ensure that appropriate policies are adhered
to with regard to Safeguarding Children and Vulnerable Adults.

d)      Clinical/care incidents

Incidents relating to service users and clinical care will also be recorded in the
individual healthcare records with a note of the Incident Report Form reference
number. Care should be taken not to include identifiable information about other
service users (third parties) in healthcare records.

Care should be taken to ensure that copies of Incident Report Forms (electronic or
paper) are not stored within paper healthcare records. They could however be
retained in a separate file kept with the records.

Incidents should also be considered for discussion in care review meetings, and care
plans amended as necessary. The review process, or rationale for not needing further
review following the incident, should also be recorded in the case notes.

e)      Service user deaths

There are many reasons why someone who is receiving care from the Trust could die,
and this may or may not be a serious incident. If the cause of death is initially unclear,
the unexpected/undetermined death of a current or recent service user (within the last
6 months), will usually be treated as a potentially serious incident and both an
Incident Report Form and Management Fact Finding Report completed.

In the event of a service user death where there have been several services/teams
involved with the care, the service or team who provided the main care would be
responsible for reporting the death as an incident. This team should ensure that
colleagues in the other involved teams are made aware of the death and confirm that
reporting has taken place, to avoid any duplication in incident reporting.

A flow chart to demonstrate the potential reporting and management arrangements for
service user deaths is available at Appendix P.

The Trust has a legal obligation to inform the Coroner of the death of any inpatient –
both informal and detained within 24 hours of the death. This will usually be done by
the responsible Consultant Psychiatrist or most senior medical staff as soon as
possible. If a crash team or ambulance has attended, the nurse in charge or general
manager will need to clarify which organisation will inform the Coroner. (See the
Trust‟s Sudden/unexpected death guidance document on the intranet for detailed
information on managing inpatient deaths.
 Incident Reporting and Management – Version 4 (17/5/10)       Page 16 of 95
 6.2      Managing an incident
a)      Immediate actions
The first priority when an incident has occurred is to ensure the immediate
safety and welfare of all those involved or affected, directly and indirectly, and
to take any necessary actions to prevent harm or further harm.
The immediate responsibility for managing an incident falls to the most senior person
on duty in the area, team or department at the time the incident occurs, or is reported
for the first time. The person managing or coordinating the response to the incident
will ensure that all necessary actions are taken to make the situation safe, which may
include:
     o Arranging for assistance to deal with the situation e.g. sounding an alarm,
       calling for emergency services, asking for immediate help from another
       department
     o Isolating or removing any risks to ensure the immediate safety of those
       involved, present or at risk, to prevent or minimise any injury or further injury to
       people.
     o Providing immediate assistance to anyone injured
     o Supporting any service users directly or indirectly involved. (See Section 8 and
       the Being Open Policy)
     o Considering the welfare of other service users, for example in a ward
       environment.
     o Supporting staff who were involved (See Section 8 and the Supporting Staff
       Policy)
     o Alerting senior managers to any serious incident
     o If the incident resulted in the death of an inpatient, ensuring that the nominated
       consultant or deputy is informed and that the death is immediately reported to
       the Coroner
     o Ensuring that service users and/or carers are provided with information about a
       patient safety incident (in which the service user has been harmed) as soon as
       possible (See Section 8 and the Being Open Policy).
     o Communicating with a service users‟ Care Coordinator, Consultant or GP.
     o Ensuring that any immediate media interest is referred to the senior manager
       and the Communications Department.
     o Contacting and liaising with the police if necessary.

b)      Managing an Incident - next steps
When immediate actions necessary to manage the incident safely have been
completed, there may be further actions required to ensure that the incident is
effectively managed:
     o Consider who needs to be informed and ensure that more senior managers are
       made aware of the incident as necessary
     o Contact/liaise with the police as necessary
     o Ensure that all potential evidence is retained intact and in safe-keeping for
       inspection. This may include clothing, equipment, messages and documents.
     o Ensure that any potentially faulty equipment is withdrawn from use. Wherever
       possible it should be removed and/or locked away. If this isn‟t immediately
       possible it should be clearly labelled as unsafe and not for use
 Incident Reporting and Management – Version 4 (17/5/10)         Page 17 of 95
   o Consider what further review, support and follow-up service users who were
     involved may need
   o Consider what further review, support and follow-up staff may need eg staff
     going off duty may need support, advice or help
   o Consider what information and support staff coming on duty may need –
     including staff returning to work from holiday or sickness absence
   o Consider which other departments or advisors may need to know e.g.
     Communications Department, Estates and Facilities, Health and Safety
     Manager, Specialist Advisers.
   o If it is likely that paper records may be required by the police or others arrange
     for photocopies to be made (see Appendix Q – record keeping following an
     incident)
   o Paper healthcare records should be secured in the case of very serious
     incidents (refer to Appendix Q) Secured means removed from use and placed
     in a secure place where they cannot be tampered with or amended.

These responsibilities may be addressed by the person managing the incident, or
passed to a more senior manager. When these have been addressed the incident
should be formally recorded – see section 6.4.

To avoid the staff member who is directly managing the incident and collecting
information being overwhelmed by information requests and expressions of
support, it is recommended that communication and support is channelled
through a single more senior manager.

 6.3     Grading the severity of incidents - the Risk Grading Matrix
Incidents that occur within the Trust will have different levels of impact and severity of
outcome. Not all incidents need to be managed or investigated to the same extent. To
enable us to understand the severity and priority of an incident all incidents are risk
graded in line with the Risk Grading Matrix developed by the Trust. (Appendix G).

Grading the severity (or risk grading) of incidents enables us to:
     •     Understand the priority and level of response that is needed.
     •     Ensure the incident is appropriately responded to in a timely manner
     •     Determine the level of investigation and analysis that is required.
     •     Take into account a range of risk factors including outcome and the
           potential for the incident to lead to a complaint or claim
     •     Analyse and compare the severity of the incidents to recognise and learn
           from trends or patterns in the adverse events that are being reported.

The grading of potential red incidents, which will be managed as Serious Untoward
Incidents (SUIs), will be confirmed by the responsible Director or nominated deputy
following the Management Fact Find process. More detailed information about grading
incidents is provided in Appendix G.

 6.4     Reporting and recording incidents
It is very important for staff to record and report what happened and what was done to
manage an incident, as soon as possible after the event. The responsibility to report
and record incidents and near misses rests with all staff involved, independent of their
seniority or professional group.
 Incident Reporting and Management – Version 4 (17/5/10)        Page 18 of 95
a)        Reporting incidents also means ensuring that:
      o   Trust managers are made aware of the incidents that they need to know about
          in a timely way
      o   Serious and significant incidents are initially reported verbally to the service or
          on call manager (as soon as possible) so that appropriate action can be taken
          to manage the situation. The Consultant or nominated deputy should also be
          informed of any serious incident involving a service user, including the death of
          a service user, as soon as possible.
      o   Some incidents will require external reporting to other agencies by the Trust
          (see section 9 and appendices L and M).
      o   Any verbal report of an incident must be followed up by completing an Incident
          Report Form (electronic or paper) within 12 hours. See action checklists for
          SUIs in Section 7.
      o   Less serious incidents are reported through the Incident Report Form only,
          without the need for a verbal report.

b)     Recording incidents means ensuring that the incident is accurately
documented. This information may be needed for a range of reasons including legal
processes, complaints and incident investigations, and analysis. Any member of staff
witnessing or involved in an incident (or the manager of the service) should ensure
that the incident is recorded using one of the methods below. The principles of
reporting incidents remain the same whichever form is completed.

 i)        Datixweb electronic Incident Report Form (IRF)
            An electronic IRF is completed for every incident, usually within 24 hours
            All relevant fields must be completed.
            The description of the incident and the action taken fields must not contain
             any person identifiable information, such as names of patients or staff, RIO
             numbers, dates of birth. This data is stored separately to the incident.
            Information entered on electronic forms must be proof read before being
             submitted to correct any mistakes.
            Staff can note the reference number following submission to enable them to
             follow up with the manager.
            Electronically reported incidents will be sent to the appropriate manager
             automatically electronically.
            In the event of the Datixweb system being unavailable (eg due to IT
             downtime or a technical fault), staff should complete a paper incident report
             form to ensure details of the incident are recorded. Information on the
             incident should be entered onto a Datixweb Incident Report Form as soon
             as possible after the system is restored.
            Areas using the electronic Incident Report Form (Datixweb) will be provided
             with training and guidance on its use by the Incident Management Support
             Team; additional guidance is available on the intranet.

 ii)        Paper Incident Report Form (IRF)
            IRF books should be available in all work areas
            Guidance on how to complete a paper IRF is printed on the front cover of
             the IRF books. The guidance explains how to complete each section of the
             form and is also available on the intranet.
            The Incident Management Support Team is available to support staff
             through this process if required.

 Incident Reporting and Management – Version 4 (17/5/10)           Page 19 of 95
            Must be legible, using black ink only.
            All relevant fields must be completed.
            Forward the completed form to the appropriate manager for approval (line
             manager, team leader, supervisor, ward/team manager) or other
             designated person (guidance for managers is available at Appendix E).

 iii)    Principles: The following principles must be followed when completing any
         IRF (electronic or paper):
          Keep it factual and accurate, not opinion or conjecture
          Detailed enough to explain what happened clearly and concisely
          Explain abbreviations, not everyone knows what we mean
          Record the subsequent actions taken in full, however minor they may seem
          Information entered should be checked prior to submitting.

 iv)     Risk Grading: All incidents should be graded using the Trust‟s Risk Grading
         Matrix as described in Section 6.3 and Appendix G).

 v)      All incidents graded Red on the Trust‟s Risk Grading Matrix are processed
         through the serious untoward incident procedures (see Section 7) and should
         also be verbally reported to the manager and Incident Management Support
         team as soon as possible to ensure they are dealt with promptly. The grading
         of potential red incidents will be confirmed by the responsible Director or
         nominated deputy following the Management Fact Find process.,

The responsibility to report and record incidents and near misses rests with all
staff involved, independent of their seniority or discipline. It is the responsibility
of managers in local teams and units to ensure this procedure is followed.

c)      Recording incidents in service user records
Incident report forms do not form part of the healthcare record and should not usually
be filed within the healthcare record – particularly as they may contain other
confidential information.

It will be appropriate to record and cross reference some incidents in the service
user‟s healthcare records. (Staff should take care to exclude any confidential
information about other parties, including names of other service users.)

IRFs may be stored in a separate filing system alongside any paper healthcare
records. A separate local incident file or file note may also need to be opened to
record other actions taken, such as contact with carers/relatives, support for staff,
contact with other agencies, police involvement, witness statements.

d)    Line manager responsibilities:
Once an IRF (electronic or paper) has been completed, the designated person should
review and approve the incident within 72 hours. The designated person is usually the
most senior person on duty at the time of the incident occurring (or being reported), ie
team leader/unit manager or line manager. It is important that managers have cover
arrangement in place so this process continues in the event of sickness and absence.

The manager is responsible for approving the content of the form. Before the manager
approves the Incident Report Form (electronic or paper), they need to be confident
that the following factors have been taken into account and are acceptable:

 Incident Reporting and Management – Version 4 (17/5/10)       Page 20 of 95
   i) Ensuring that the IRF is fully and accurately completed in line with guidance at
        Appendix D.
   ii) Ensuring that the content of the IRF is a true record, and adding any further
        information as necessary.
   iii) Reviewing the grading of the incident and if necessary amending this in
        consultation with the staff member
   iv) Alerting a more senior manager, and the incident management support team to
        serious and significant incidents (see section 7 for specific guidance on
        reporting and managing serious untoward incidents)
   v) Ensuring the IRF is processed in a timely manner according to its severity, to
        ensure it receives the appropriate response
   vi) Ensuring that a book of paper IRFs is available in the event that Datixweb is
        unavailable. This ensures that data about an incident is logged at the time.
        Managers should ensure the information is entered onto Datixweb as soon as
        possible after the system is restored.

 6.5     Management Fact Find Report
Following an adverse incident, the immediate information may be limited and further
information will only become available in subsequent hours /days.

Once an incident has been reported and recorded on an IRF further information may
be required by senior Trust officers to assist with decisions about grading, external
reporting and the level of investigation required. This will depend on the severity and
significance of the incident.

A Management Fact Find Report template has been developed for this additional
information to be recorded and communicated (available as Appendix K). The Report
should be completed for all serious incidents (amber and red) within 48 hours of the
incident being discovered. The completed Report should not contain any confidential
identifiable information and should always be password protected prior to emailing if
they contain potentially identifiable information.

Each section of the form template acts as a „check list‟ for service managers on issues
to consider, although not all sections of the form will be relevant to each incident. The
form records:
  More detailed information about the incident and/or the care of the person affected
   by the incident including:
        o Additional facts surrounding the incident
        o Additional details about the person affected, not already given on the
            incident report form
        o Any significant events leading up to the incident
        o Information on findings of an initial risk assessment of systems and
            processes
  Any emerging issues that require immediate action or further investigation
  Actions taken to manage the incident , including:
        o Details of communication with service users or carers (Being open)
        o Support provided to staff
        o Actions to improve safety and prevent recurrence
        o External reporting or liaison


 Incident Reporting and Management – Version 4 (17/5/10)       Page 21 of 95
 Completing Management Fact Find Reports
 Incident severity           Timescales                            Who needs the
                                                                   completed report?
  Red incident (SUI) - including      Initially within 48 hours
   potential red incidents (SUIs)      (working) of the            o Responsible manager
  Amber incidents                     incident occurring (or        eg General Manager
  Unexpected service user             first being identified)       (or equivalent)
   death                                                           o Responsible Director
 (In some situations responsible       Further updates may         o Incident Management
 Director may decide that the          be required as more           Support Team (via
 Management Fact Find Report           information becomes           risk@swyt.nhs.uk)
 is not required).                     available

Once completed, the Report should (where possible) be uploaded onto Datixweb as a
document to the incident record. The Incident Management Support Team will then
ensure the report is circulated as appropriate.

If it isn‟t possible to upload the document onto Datixweb it should be e mailed to the
relevant senior manager and responsible Director. The Incident Management Support
Team (risk@swyt.nhs.uk) will then save the document in the incident record on Datix
and ensure the report is circulated as appropriate.

In some cases (amber or unexpected death) a comprehensively completed
Management Fact Find Report may, at the discretion of the responsible manager, act
as the investigation report. However it may be decided that additional information is
required through further local investigation.

7.0 Reporting and managing Serious Untoward Incidents
    procedure (incidents graded Red)
 7.1     Reporting Requirements
Serious untoward incidents are the most serious and significant incidents, which can
include some near misses. It includes incidents that had very serious consequences,
such as serious injury or the death of a service user, staff member or visitor. These
incidents therefore need to be managed with care and consideration within the Trust,
both at the time of the incident and afterwards. It is essential that the Chief Executive
is made aware of the incident as quickly as possible. Prompt incident reporting will
ensure that this happens through existing incident management processes.

Serious incidents also have to be reported externally. Which agencies need to be
involved and within what timescale will depend on the exact nature and severity of the
incident (see section 9 and appendices L and M). However all SUIs and potential SUIs
need to be reported to the relevant PCT within 24 hours of the incident, and to the
SHA immediately if there is, or is likely to be media attention. Immediate reporting of
high profile incidents to the SHA will usually be through the responsible Director or
deputy, including the on-call Director out-of-hours. Forma reporting to the relevant
PCT will be done by the Incident Management Support Team (once sufficient
information to clarify the severity and grading of the incident is available) via the
Department of Health SUI electronic information system (STEIS/SIMS). Reporting to

 Incident Reporting and Management – Version 4 (17/5/10)           Page 22 of 95
other external agencies will be coordinated by the IMST and sometimes a specialist
adviser (see appendices).

If there is any doubt as to whether or not an incident meets the SUI reporting criteria,
the Incident Management Support Team can provide guidance and if required, contact
the PCT or SHA for advice. Examples of SUIs are available in Appendix I. Early but
sketchy information about a potential incident is better than more detailed informed
being provided late. In circumstances where information about an incident is unclear
the SHA/PCT will maintain a „watching brief‟ on an incident until further information is
available.

 7.2     Serious untoward incidents – who to inform and when
It is important that key people are alerted to an SUI or potential SUI as soon as staff
are made aware of the incident. Although in inpatient settings staff will usually be
immediately aware when an SUI has occurred, there may be a delay in other care
settings. For example, staff may be alerted to a serious incident or death by the police
or the Coroner some time after the death occurred. Confirmation of the grading of
potential red/SUIs will be given by the responsible Director or nominated deputy
following the Management Fact Find process.

Some serious incidents require prompt reporting to external agencies (see section 9
and appendices L and M), so it is essential that that these incidents are reported as
son as possible within the Trust.

The first priority when an incident has occurred is to ensure the immediate
safety and welfare of all those involved or affected, directly and indirectly, and
to take any necessary actions to prevent harm or further harm.

Any member of staff discovering a serious incident (or potentially serious
incident) should ensure that they alert the most senior person on duty in the
area, team or department, as soon as possible. Out of office hours this will
mean contacting the On-call manager through Fieldhead switchboard.

 7.3     Serious Untoward Incident action checklists - overview
The following procedural checklists set out the actions to take in the event of a serious
untoward incident occurring. These checklists should be held in an accessible place
with relevant contact telephone numbers/safe-haven fax numbers, to ensure that
information is accessible in an emergency situation.

The checklists include the immediate actions that might need to be taken to ensure
the situation and people involved are safe, along with responsibilities and the reporting
arrangements. Details of duties, roles and responsibilities in managing incidents
(including those graded red) are given in Section 4.

These checklists are a guide; judgement should be used and actions will be
dependent upon an individual situation. Not all actions will be relevant to each
incident.




 Incident Reporting and Management – Version 4 (17/5/10)       Page 23 of 95
a)   Checklist A: Responsibilities of person in charge of unit, team
or department following a serious incident

Checklist A: Responsibilities of person in charge of unit, team or
department following a serious incident
Immediate responsibility for managing/coordinating the response to an incident falls to
the most senior person on duty in the area, team or department at the time the incident
occurs (or when the incident is first reported). This person will need to ensure that all
necessary actions are taken to make the situation safe and follow correct procedures.

TIMESCALE          ACTIONS TO BE TAKEN, AS APPROPRIATE

 Immediate Actions
                          Arrange for assistance to deal with the situation e.g. sounding an
Priority: to               alarm, calling for emergency services, asking for immediate help from
ensure                     another department
everyone is               Ensure the safety of an individual or individuals
safe                      Make sure the area is made safe
                          Isolate or remove any risks to ensure the immediate safety of those
                           involved, present or at risk, and to prevent or minimise any
                           injury/further injury to people
 Verbal Reporting:
                   Verbally report the incident to the General Manager or equivalent:
                     During office hours – inform the General Manager/equivalent/deputy
                     Out of hours – inform the On Call Manager through the appropriate
                       switchboard (see Appendix T for contact numbers)
 Evidence (person in charge)
                    Protect the incident scene (unless it constitutes a continuing hazard)
                    Secure (or protect) any „evidence‟ necessary; eg equipment, incident
As soon as      scene - ensure nothing is removed from the scene until authorisation has
possible after  been given (unless it constitutes a continuing hazard)
situation has  Paper records:
                 - Gather all relevant paper records together and secure them for the
been made
                   responsible manager to ensure no further entries are made (see
safe               Appendix Q – managing records following adverse events)
                      - The original records may be required by other agencies, e.g. Police or
                        Coroner - so ensure a copy/copies of the full set of any paper records is
                        taken for Trust reference/investigation processes or ongoing treatment
                        (liaise with medical records)
                    Electronic healthcare records: ensure an entry is made recording the
                     incident including the date and time
                    Ensure that a separate file/record is set up to contain full and accurate
                     records of decisions and actions taken following the incident
 Next Steps (person in charge):
                   Support: (see separate Supporting Staff and Being Open Policies)
As soon as      Ensure an appropriate member of staff is identified to inform service
possible after   user/carers/relatives in conjunction with the responsible manager. This
situation has    should be done before any media involvement if at all possible.
been made       Offer practical, personal emotional support to members of staff involved as
safe             appropriate
                    Ensure that other service users are supported
                    Ensure key members of staff in the care team are aware of the incident
Incident Reporting and Management – Version 4 (17/5/10)           Page 24 of 95
                   Liaison:
                    Inform the Consultant Psychiatrist and/or Senior Clinician and/or care
                     coordinator of a clinical incident
                    Inform other agencies of the incident as appropriate eg Police, Coroner,
                     Mental Health Act Commission (see Appendices L and M).
                    Check links with other Trust policies, Vulnerable Adults, Child Protection,
                     Health and Safety (see Appendices L and M and Section 13)

 Formal Reporting:
                   It is essential that a formal record is made of the incident, as soon as
Within 12          possible after the event, to formally and accurately record and report what
hours              happened and what was done to manage the situation
                   The Person in Charge, in conjunction with the staff involved should:
                    Complete an electronic or paper IRF as soon as possible after the
                     situation has been made safe. See Appendix D
                    Record all actions taken to manage the incident, ensure the safety and
                     well-being of those affected and minimise the risk of reoccurrence
                    Record who has been informed of the incident, by whom and when
                    Electronic IRFs: the electronic form will be automatically flagged up to the
                     appropriate manager dependent upon the grading.
                    Paper IRFs: a copy of the form should be kept in the service area for
                     future reference. Hand-deliver or fax (to Safehaven fax) the paper form to
                     the responsible Manager within 12 hours

                      Take witness statements from staff involved. (See Appendix S – on
Ongoing                Witness Statements and the Supporting Staff policy)
                      Continue to liaise closely with the responsible manager on current
                       situation & further actions taken
                      Continue to collect further information about the incident that may
                       become available (complete management fact finding report)
                      Contribute to the investigation process as required (see procedural
                       document on investigating and analysing incidents, complaints and
                       claims to learn from experience)




Incident Reporting and Management – Version 4 (17/5/10)            Page 25 of 95
b)    Role of Responsible Manager (including On Call Manager**)
      following a serious incident

Checklist B: Role of Responsible Manager following a serious
incident (including On-Call Manager)
The person in charge of the unit, team or department will verbally notify the General
Manager or equivalent (the Responsible Manager). The Responsible Manager is then
responsible for ensuring that the incident is managed appropriately and that it has been
reported promptly. Out of hours this will usually initially be the on-call manager.
TIMESCALE        ACTION TO BE TAKEN, AS APPROPRIATE

 Immediate Actions - dependent upon the incident
                 The responsible manager will ensure that:
Immediate
actions to       Safety (see Checklist A for detailed list)
secure the        The environment has been made safe
situation         Any immediate actions to prevent recurrence are taken
                 Support and Communication (see also Supporting Staff and Being Open
                 Policies)
                  Service users and their family/carer are informed about an incident before
                   any media attention if possible (Responsible Manager should liaise with
                   Communication Department)
                  Support is offered/provided to the service user and/or their family/carer by
                   an appropriate member of staff (taking into consideration the welfare of any
                   children involved in line with Safeguarding Children Guidance). Support for
                   staff undertaking this role should be provided
                  Members of staff involved in the incident are supported and other key
                   members of staff who may be affected are informed of the incident
                  Staff coordinating/managing the incident are not overwhelmed by inquiries
                   and information requests from different sources in the Trust – establish a
                   clear communication link / process to prevent this
                  Police and/or Coroner‟s office are contacted as necessary
                 Evidence
                  The scene may need to be secured until the police authorise it to be
                   released (however, some judgment may be required where this impacts on
                   safe working practice)
                  Evidence from the scene is secured, and/or stored safely
                  Witness statements have been taken (Trust Legal Services can provide
                   support with this and guidance can be found in Appendix S)
                 Managing Records (see Appendix Q)
                  Paper records - ensure:
                    - All relevant paper records have been collected and secured so no further
                      entries can be made in clinical records
                    - A copy of the full set of any paper records has been/is being taken for
                      Trust reference/investigation processes - if the original records are
                      required by other agencies e.g. Police, Coroner
                    - That secured paper records are retained in a central location with a
                      system to record requests for access, by whom, when etc.
                    - That the clinical team have a copy of the patient notes so that continuous
                      records can be made
                  Electronic healthcare records: ensure an entry is made recording the

Incident Reporting and Management – Version 4 (17/5/10)           Page 26 of 95
                     incident, including the date and time
                  Ensure a file is established to record management of the incident, to include
                     records of all communication, discussions, actions, decisions & rationale,
                     with details of dates, times, names etc - include actions taken in relation to
                     communications with carers/relatives (Being Open) & supporting staff
 Verbal Reporting:
                 The responsible manager will verbally report the serious incident as soon
Report as        as possible:
soon as
                     During Office hours:
possible               o Inform the relevant responsible Director as soon as possible
                       o Inform the Incident Management Support Team on 01422 281334
                     Out of hours: :
                       o Inform the on call Director (see Appendix T for contact details)
                     Ensure other agencies are informed of the incident as necessary eg Police,
                      Coroner, Mental Health Act Commission, Health & Safety Executive (see
                      Appendix L & M)
                     Check links with other Trust policies: Vulnerable Adults, Safeguarding,
                      Health & Safety (see Section 13) & cross-over with other agency policies
 Formal Reporting:

Within 12        The responsible manager will:
                  Receive the IRF via Datixweb or
hours
                  Paper forms should be either entered on Datix via local access as a priority,
                    or faxed to the Incident Management Support Team as soon as possible
                    (contact 01422 281333 to arrange safehaven fax)
                  IMST will have automatic access to forms entered electronically
                  Initiate a further fact finding exercise to identify further information and risk
                   issues and inform completion of the Management Fact Find report
 Management Fact Find Report:

Within 48        The responsible manager will:
                  Liaise with the relevant service manager to gather addition information
hours
                  Ensure that the Management Fact Finding Report is completed & attached
                    to Datixweb or sent to the relevant Director and IMST risk@swyt.nhs.uk

Severity /       After completion, circulation & review of Management Fact Find Report:
                  Confirm the severity/risk grading
risk
                  Responsible manager or Director instigates Trust investigation appropriate
Grading
                    to the severity of the incident - in accordance with Investigating & analysing
                    incidents, complaints & claims to learn from experience Procedure
                  If incident is red/SUI: IMST will report the SUI to the SHA and/or PCT
 Next Steps

Ongoing              Being open and supporting staff processes – as appropriate
                     Refer to the procedural document on Investigating and analysing incidents,
                      complaints and claims to learn from experience Policy for information on
                      setting up and supporting an investigation and learning lessons.
                     If relevant ensure that the Trust‟s „Undetermined Death Audit
                      questionnaire‟ is completed during the investigation process (while
                      healthcare records easily accessible)




Incident Reporting and Management – Version 4 (17/5/10)              Page 27 of 95
     C) Out of Hours Arrangements
If a serious incident (potential SUI) occurs out of normal office working hours, the
following should be followed:

 i) Person in charge of the unit/team or department will verbally report the incident
    to the on call manager via the appropriate switchboard (Appendix T).

 ii) The On call manager will:
      Report the incident to the On Call Director
      Ensure the serious incident procedure is followed in line with the actions set
        out in Section 7- Checklists A and B.
      Maintain a written record of all communication, discussions, actions, decisions
        & rationale, with details of dates, times, names etc - include actions taken in
        relation to communications with carers/relatives (Being Open) and Supporting
        Staff
      Ensure staff coordinating/managing the incident are not overwhelmed by
        inquiries and information requests from different sources in the Trust –
        establish a clear communication link / process to prevent this
      On return to normal working hours, handover to the appropriate responsible
        manager and inform the Incident Management Support Team

 iii) The On call Director will:
       Liaise with services to support the safe and appropriate management of the
         incident (see Section 7, checklists A and B above).
       If the severity of an incident needs immediate support from the SHA, eg in
         cases where there may be significant media attention, the SHA on-call
         manager can be contacted on 07699 760979.
       Consider informing the Trust‟s on-call Communication team
       Ensure staff coordinating/managing the incident are not overwhelmed by
         inquiries and information requests from different sources in the Trust –
         establish a clear communication link / process to prevent this
       Maintain a written record of all communication, discussions, actions, decisions
         & rationale, with details of dates, times, names etc - include actions taken in
         relation to communications with carers/relatives (Being Open) and Supporting
         Staff Ensure records are kept during this time. If appropriate, these should be
         filed in the trust SUI file (held by IMST).
       On return to normal working hours, handover to the appropriate responsible
         Director

d)       Responsibilities of the Incident Management Support Team
         following a Serious Incident
The Incident Management Support Team‟s responsibilities in relation to managing
Serious Untoward Incidents will be to ensure that:
     •   Trust policies and procedures are compliant with external standards and
         requirements
     •   Potential and confirmed Serious Untoward Incidents are reported to relevant
         individuals within the Trust as soon as possible. This will include informing the
         Chief Executive, Chairman and Vice-Chairman, Communications lead and
         relevant Directors.
     •   SUIs are reported to external agencies as required. This may include:
 Incident Reporting and Management – Version 4 (17/5/10)         Page 28 of 95
             - The relevant Primary Care Trust and Strategic Health Authority within 24
               hours (via STEIS/SIMS) in line with the SHA SUI procedures.
             - SUIs relating to patient safety are reported to the National Patient Safety
               Agency (NPSA) via the National Reporting and Learning System
             - Some serious incidents have to be reported to the CQC
   •   A central Trust SUI record/file (electronic and/or paper) is maintained for each
       SUI. This will include evidence of the SUI process, file notes. A file tracer will be
       in place for paper files.
   •   Responsible managers and investigators are provided with investigation
       support pack/templates.

8.0 Communication, information and support
This section should be read in conjunction with the Trust‟s Being Open Policy and
Supporting Staff following Adverse Events Policy. These documents are available on
the Trust intranet.

Some incidents can be distressing or traumatic for those who have been directly or
indirectly involved - service users, carers, relatives and/or staff. Care should be taken
to ensure that those people who may be affected by an incident are identified and
every effort made to offer appropriate information and support both immediately post
incident and in the longer term. The following groups should be considered:
      Service users who are directly affected or harmed by an incident
      Carers/relatives of a service user who has been harmed or who has
       perpetrated an incident
      Service users who have either witnessed or in some other way been affected
       by an incident e.g. on an inpatient ward at the same time, or know someone
       else who has been affected.
      Visitors, including carers, who may have been involved in or witnessed an
       incident
      Staff directly involved in an incident
      Staff who are members of a team where there has been an incident
      Staff who have worked with a service user who has been harmed
      Bank or agency staff, and students who may not usually work with the service
       but who may have been affected in some way

The level of support required may vary according to:
      the nature and severity of the incident,
      the support network around the service user, relative, carer or staff member,
      the resilience and personal resources of the people involved.

 8.1     Patient/relative/visitor/contractor communication, information
         and support (see Being Open policy)
In some situations service users and/or their carers directly affected by an incident will
need to be contacted to provide information about what has happened. This is
particularly the case where a service user has been harmed as a result of a patient
safety incident (see Trust‟s being open policy). Every effort must be made to ensure
that the service user and relatives/carers are informed of relevant information before
the media.
 Incident Reporting and Management – Version 4 (17/5/10)        Page 29 of 95
Communication must be open, honest and accurate, ensuring that the right
information is given in a sensitive, timely fashion and that service users and carers
have ample opportunity to ask questions.

Careful consideration should be given to who will communicate with service users and
carers following a patient safety incident or other serious incident. Although this may
have to be done quickly, it must be carried out by an appropriate person with sufficient
training and experience. Wherever possible this will be through a face-to-face
meeting. The following will be offered as and when appropriate:
       Factual information about what has happened
       An apology or expression of regret for any harm suffered
       An explanation of what actions the Trust has already taken to minimise any
        harm
       An explanation of what further action the Trust intends to take to address the
        situation and if possible prevent or minimise any further harm to those
        concerned.
       An offer of support
       An offer of further communication and contact
       An identified contact person

Actions taken in relation to contacting and communicating with patients, relatives and
carers (being open) should be recorded in a local incident file/file note. If a decision
was taken not to make contact or provide information the rationale for this should be
recorded.

 8.2     Support for staff (also see Supporting Staff policy)
Being involved in an incident or a „near miss‟ can be a difficult experience for staff,
particularly if someone has been harmed or has died. Staff may also be affected if
they were a witness to an incident, if something has happened to a service user that
they were working with, or if something has happened to a colleague.

Staff can sometimes feel very isolated after an incident, particularly if they are absent
from work or if they do not work within the team where the incident took place; agency
staff or students can feel particularly isolated and excluded.

Wherever possible communication with staff following an incident should be open and
honest, and support should be offered in accordance with the Trust‟s supporting staff
policy. Support may be required immediately, and/or at a later stage or be ongoing. It
may need to be practical and/or emotional depending on the circumstances and the
individual.

 8.3     Process by which to raise concerns
Service users and carers can raise concerns directly with staff or through the Trust‟s
Customer Care service.

Staff should consult other Trust policies and procedures that may be relevant, as listed
in Section 13, such as the Whistle-blowing policy and procedures, Harassment and
bullying policy, Stress (work related) policy.
 Incident Reporting and Management – Version 4 (17/5/10)       Page 30 of 95
9.0 External notification and communication
The Trust does not work in isolation; as a service provider and as an employer the
Trust works closely with a range of partner organisations within a legal and statutory
framework. We have to provide information about our working practice and adverse
events to a number of external agencies. A list of key stakeholders is included as
Appendix M.

Where relevant the Trust is committed to working with other relevant agencies to
investigate, resolve and learn from adverse events. These arrangements are always
subject to legal requirements, such as the Data Protection Act.

a)      Working with partner agencies and in joint teams
If an incident occurs involving a joint-agency team or cross-agencies issues, where a
comprehensive investigation is needed, the appropriate managers for the relevant
agencies will agree on the investigation arrangements and on the lead organisation for
the investigation. If the Trust decides to involve external parties in any investigation
the SHA would expect to be notified and to have sight of the terms of reference.

In some services Trust staff work in joint teams where staff are employed by different
organisations, such as the Trust and Social Services, and/or work in premises
provided by a different organisation. The service or team leader for a joint team should
ensure that incident reporting arrangements are agreed with all the organisations
involved and that all staff are clear how and where to report any type of incident. This
may require a local written procedure.

In some situations there may be an agreement in place for incidents to be reported to
more than one organisation. For example incidents relating to the actual premises
may need to be reported to the organisation responsible for the building but incidents
relating to client care may need to be reported to the employing organisation. Some
incidents may relate to both the premises and client care so need to be reported to
both organisations.

b)     External reporting of incidents
Some incidents have to be reported to external organisations and bodies to enable
external scrutiny of our practice and/or to ensure warnings and learning can be shared
with other organisations. Systems and processes have been put in place to support
these requirements. A list of external and internal stakeholders and supporting
information is available at Appendices L, M, T, U,V and W.
     All patient safety incidents are reported to the National Patient Safety Agency
      (NPSA) through the National Reporting and Learning System (NRLS)
     Serious and significant incidents are reported to the commissioning PCT via the
      D of H Serious Untoward Incident reporting system (STEIS/SIMS).
     Serious child safeguarding incidents are initially reported to the commissioning
      PCT who will then report to the SHA via the D of H SUI reporting system
      (STEIS/SIMS) and who will then also coordinate health service investigation
      into the incident, including involvement in the Serious Case Review process.
     The Department of Health requires serious incidents involving confidentiality
      breaches to be reported via the STEIS/SIMS database.

 Incident Reporting and Management – Version 4 (17/5/10)      Page 31 of 95
     Serious injuries are reported to the Health and Safety Executive (RIDDOR –
      Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995)
     The CQC (Care Quality Commission) is notified of a range of serious incidents
      and events either via the NPSA, the SHA or directly by the Trust (via the
      Director with responsibility for incident management and the assistant director
      with responsibility for compliance). These notifications form part of the legal
      requirements for registration under the Health and Social Care Act 2008 (see
      appendix W.
     Information about suicides and homicides is collected by the National
      Confidential Inquiry into suicides and homicides by people with mental illness
     Other agencies such as Mental Health Act Commission, Local Authority and
      neighbouring trusts.

c)    Post incident communication
The Trust will ensure that following a serious incident which also involves or affects a
partner NHS organisation that communications about the incident are established and
maintained at different levels, such as:
            Clinician to clinician
            Management lead to management lead
            Communications lead to communications lead
If there is a need to issue a press statement in relation to an incident, this may be
done in collaboration with another NHS organisation or partner agency via the Trust
Communications team.

d)    Statutory Bodies
Each NHS Trust has a responsibility to work with statutory bodies; this procedure does
not supersede the requirements to notify other agencies of certain incidents.

e)    External and shared policies, procedures and protocols
The Trust works within a number of protocols and procedures which are led by or
shared with other organisations and agencies. These include:

       MAPPA (Multi Agency Public Protection Arrangements) - led by the
        Probation Service
       Memorandum of Understanding - Investigating patient safety incidents
        involving unexpected death or serious untoward harm; a protocol for liaison
        between the NHS, the Association of Chief police officers and the NHS Health
        and Safety Executive.
       Missing Service Users/patients Policy and Procedure - a joint protocol with
        West Yorkshire Police and the West Yorkshire Mental Health Trusts.
       Safeguarding Children – West Yorkshire Wide Procedures across Local
        Authority areas (April 2007) - web-based.
       Safeguarding Vulnerable Adults - the Trust accepts the principles laid down
        within Calderdale, Kirklees and Wakefield Local Authorities multi-agency Adult
        Protection policies and procedures and is committed to working in partnership.
        Each policy can be found on the Trust intranet or via access to the appropriate
        local authority website


 Incident Reporting and Management – Version 4 (17/5/10)       Page 32 of 95
10.0 Managing inquiries from the media or the public
a)   Media Attention
Some incidents may attract attention from the media, members of the general public,
MPs and elected members or independent organisations. Some of these incidents
may have a very high level of media and public interest and could generate calls to a
number of different departments of the Trust. This may include requests which are
made under the Freedom of Information Act 2000.

All communications about an incident must be handled sensitively to avoid breaches
in confidentiality, to avoid misunderstandings and to ensure that people who may be
directly affected can be properly informed or consulted before information is made
public. All enquiries about an incident from any body or organisation not directly
involved or affected by an incident will be handled and co-ordinated by the
Trust‟s communication team (see contacts page, Appendix T).

Following an incident which has or could attract media attention staff will:

      Immediately inform the communications team or a more senior manager if an
       incident occurs that could or has already attracted media or public interest. (If in
       any doubt it is better to make the communication team or a senior manager
       aware.)
      If contacted by the media or someone from the general public, explain that the
       communication team will be able to respond to their questions and take details,
       then inform the communication team as soon as possible - or contact a more
       senior manager.

Managers will remind staff to refer calls to the communication team following incidents
which could attract media or public interest.

b)     Hotline Arrangements
Should an incident result in a high level of media interest or multiple enquires from the
public, then plans for handling the media will be put into action. The Trust‟s media
handling policy will be implemented with the Manager in charge of the incident liaising
with the Communications Manager.
Reference should be made to the Media Handling Policy, Major Incident and Business
Continuity Policy and guidance in Appendix R on arrangements for 'help lines' for
dealing with multiple enquiries by patients (service users), relatives and the media.
Every effort must be made to ensure that the patient (service user) and
relatives/carers are informed of relevant information prior to the media.

c)     Freedom of Information Act 2000
In the event that the Trust receives any requests for information regarding Serious
Untoward Incidents under the Freedom of Information Act 2000, the Trust must inform
the Strategic Health Authority of the request.

d)     Inquiries from people directly affected by an incident – service users,
carers, relatives, staff
Information about communicating with and supporting people affected by an incident
is provided in the Trust‟s Being open and Supporting staff policies.


 Incident Reporting and Management – Version 4 (17/5/10)        Page 33 of 95
11.0 Investigating and analysing incidents to learn from
     experience
 11.1 Investigating and analysing incidents
Investigating and analysing incidents to learn lessons is an essential part of effective
incident management. It enables the organisation to identify how systems and
processes can be improved to prevent the same things happening again. We can
learn from investigations into individual incidents, and also by analysing and reviewing
clusters, trends or patterns, which could be through the analysis of aggregated data or
a management awareness of a locally repetitive occurrence or practice.

The Trust‟s approved document, Investigating and analysing incidents, complaints and
claims to learn from experience describes these Trust processes in detail including:
             Identifying the level of investigation required (see flowchart below)
             Investigations and root cause analysis
             Complex investigations and investigations involving external agencies
             Risk management and reduction
             Action planning
             Analysis of incident information
             Learning from experience

 11.2 Managing risks: implementing risk reduction measures and
      inclusion of risks on the risk register
Effective incident management involves reviewing and analysing incident information
to support risk management, learning and improvement. (See also ‘Investigating and
analysing incidents, complaints and claims to learn from experience policy and
procedure‟.) Incidents of all levels of severity require an appropriate level of review:
            Ensure that risks are identified, assessed and understood
            Review how the risks are currently managed and if this is adequate
            Identify any further actions required to control or reduce the risks
            Review/monitor the effectiveness of these measures
            Record this process
The generic risk assessment format can be used to record/support this process
(Appendix N).
 There are different levels and different stages at which risk reduction measures may
 be taken, which will be influenced by the severity and circumstances of the incident/s
 including the potential for recurrence:

 i. Immediately post incident some level of risk assessment is required, following the
     process described above. This process, including any risk reduction measures,
     can be recorded on the IRF and if appropriate in the healthcare records (eg a care
     plan review). This may apply to incidents of all severity grading, and may be the
     only action required for less serious incidents.
 ii. Management Fact Find process and report – amber and red incidents require a
     Management Fact Find within 24 – 48 hours, which includes a review of risks as
     described above. This should be recorded on the Management Fact Find Report
     and may require completion of an action plan.
 Incident Reporting and Management – Version 4 (17/5/10)          Page 34 of 95
 iii. Some serious incidents will then require further investigation using Root Cause
      Analysis, which will identify risks and appropriate actions to reduce or manage
      these, which may require completion of an action plan.
 iv. In addition aggregated incident data will need reviewing to identify any clusters or
      hot spots.

Risks which cannot be eliminated or reduced to an acceptable level by local services
will be referred to the responsible senior manager for consideration, and may need to
be included on the appropriate risk register through the service management group
(see Trust‟s Risk Management Strategy).

The Trust recognises that the organisation works within a high-risk environment. We
are required to achieve a balance between providing appropriate care and treatment
to those who use our services, positive risk taking for therapeutic reasons and public
protection. The Trust expects and supports staff to take informed, measured and
managed positive risks with service users.

12.0 Dissemination and Implementation
 12.1 Dissemination
This policy will be disseminated in accordance with the Trust Policy for the
development, approval and dissemination of policy and procedural documents. Once
approved, the integrated governance manager will be responsible for ensuring the
updated version is added to the document store on the intranet and is included in the
team brief.

 12.2 Implementation
Implementation of this policy will be through the key roles of the responsible directors
and senior service managers, supported by the incident management support team
IMST).

Responsible directors and service managers will:
   Ensure staff are aware of this policy
   Ensure staff are appropriately trained and supported to undertake this role
     through appraisal and supervision.
   Provide support to staff involved in incidents and near misses
   Ensure systems are in place to review incident information at a local level

Incident management support team will:
    Maintain the Datix database and other systems to enable and support the
      process.
    Promote awareness of this policy to staff as opportunities arise
    Provide monitoring and support on the processes for reporting incidents and
      near misses

All new staff will receive incident and risk management training as part of their
induction programme. Risk assessment and management has been mapped through
the Knowledge and Skills Framework (KSF) and will be monitored through the


 Incident Reporting and Management – Version 4 (17/5/10)       Page 35 of 95
management supervision and appraisal process. Training needs identified will be
recorded on the Trust wide Training Needs Analysis

13.0 Process for monitoring compliance with this document
The Director with responsibility for incident management is responsible for monitoring
compliance with this policy. This will be achieved through:
     1. The ongoing monitoring role of the incident management support team.
     2. Incident management support team will make data and information reports
        available within the Trust
     3. Audits of the process – either as a whole, or of specific aspects
     4. Feedback from external agencies:
         Feedback reports from the National Patient Safety Agency
         The NHS Litigation Authority Assessment process
         SHA and PCT performance management processes

Relevant concerns will be reported to the nominated responsible director and/or the
Executive Management Team.

     Standard                               Monitoring process - evidence:
1.   This document is reviewed and          The document on the intranet is up-to-date
     updated in accordance with Trust
     policy to ensure that it is up to
     date.
2.   Relevant staff will be made aware         Document is on the intranet
     of the policy and offered support         Reference in team brief
     and training                              Induction presentation to new staff
                                               Teams receiving Datixweb training have
                                                been given information on the policy
3.   Incident Management Support               Monitoring incident reporting and data
     Team will monitor compliance               quality via Datixweb
     with this policy                          Serious Untoward Incidents are identified
                                                and reported to the SHA / PCT
                                               Patient Safety incidents are sent to the
                                                National Patient Safety Agency via the
                                                National Reporting and Learning System
                                                on at least a monthly basis.
                                               Data and information reports are prepared
                                                from incident database and made available
                                                for review at Trust groups
4.   Reporting to external agencies            Evidence of reporting incidents to external
                                                agencies/bodies

14.0 Associated documentation
This includes Trust supporting/linked procedural documents which should be used in
conjunction with this document. A full list of current Trust policies, procedures and
guidelines is available on the Trust intranet system.

Trust documents:
 Investigating and analysing incidents, complaints and claims to learn from
   experience Policy and Procedures
 Incident Reporting and Management – Version 4 (17/5/10)           Page 36 of 95
     Being Open policy
     Supporting Staff following Adverse Events Policy
     Claims Management Policy and Procedure
     Complaints Management Policy and Procedure
     Child Protection Manual and Policy
     Health and Safety policies, procedures and processes
     Human Resources and related policies and procedural and related documents
     Information Governance (and Caldicott Guardian) related policies and procedural
      documents
     Major Incident and Business Continuity Plan
     Media and Communications – related policies and procedural documents
     RCA support tool
     Sudden/unexplained deaths – management guidance for staff

Interagency documents and processes
 MAPPA (Multi Agency Public Protection Arrangements) - led by the Probation
    Service
 Memorandum of Understanding: Investigating patient safety incidents involving
    unexpected death or serious untoward harm; a protocol for liaison between the
    NHS, the Association of Chief police officers and the NHS Health and Safety
    Executive
 Missing Service Users/patients Policy and Procedure - a joint protocol with West
    Yorkshire Police and the West Yorkshire Mental Health Trusts.
 Safeguarding Children – West Yorkshire Wide Procedures across Local Authority
    areas (April 2007) - web-based.
 Vulnerable Adults (prevention of abuse of) - the Trust accepts the principles laid
    down within Calderdale, Kirklees and Wakefield Local Authorities multi-agency
    Adult Protection policies and procedures and is committed to working in
    partnership. Each policy can be found on the Trust intranet or via access to the
    appropriate local authority website
 NHS Yorkshire and the Humber Strategic Health Authority
       o Procedure for the management of Serious Untoward Incidents (SUIs)
       o Good practice principles for incident management (which is integrated into
           Trust policies and the Root Cause Analysis support tool.

15.0 References
This section provides the evidence base and references for this policy

SHA
NHS Yorkshire and the Humber: Procedure for the management of Serious Untoward
Incidents (SUIs) Version 5 – March 2010 (requirements are incorporated into this
document.)
Department of Health
      o An Organisation with a Memory: Report of an Expert Group on Learning from
        Adverse Events in the NHS. London: Department of Health.
      o Building a Safer NHS for Patients: Implementing an Organisation with a
        Memory. London: Department of Health.
      o 1998 Health Service Circular 1999/198, The Public Interest Disclosure Act
        1998: Whistle blowing in the NHS. London: Department of Health.

    Incident Reporting and Management – Version 4 (17/5/10)   Page 37 of 95
   o Independent Investigation of Adverse Events in Mental Health Services
     London: Department of Health.
   o Health Service Circular 1999/198, The Public Interest Disclosure Act 1998:
     Whistle blowing in the NHS. Chapter 23. London: The Stationery Office.
     Available at: www.opsi.gov.uk
   o Records Management - NHS Code of Practice 2006, Department of Health
Health and Safety Executive
  o Health and Safety (Consultation with Employees) Regulations 1996. (Statutory
      Instrument 1996 No. 1513). London: The Stationery Office. Available at:
      www.opsi.gov.uk
   o 1995 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
     (RIDDOR Explained, Version 6), Suffolk: Health and Safety Executive.
     Available at: www.hse.gov.uk

National Patient Safety Agency
   o 2004 - Seven Steps to Patient Safety. London: National Patient Safety Agency.
     Available at: www.npsa.nhs.uk/
   o 2005 - Building a Memory: Preventing Harm, Reducing Risks and Protecting
     Patient Safety London: National Patient Safety Agency.
   o 2009 – Being open: saying sorry when things go wrong. Communicating patient
     safety incidents with patients, their families and carers. London: National
     Patient Safety Agency
   o 2009 - Being open: Patient Safety Alert: NPSA/2009/PSA003
   o 2009 - Being open: Patient Safety Alert: NPSA/2009/PSA003 - Supporting
     information
   o 2008 - Independent investigation of serious patient safety incidents in mental
     health services: Good practice guidance.
   o 2009 - National Reporting and Learning Service (NRLS) Data quality standards
     - Guidance for organisations reporting to the Reporting and Learning System
     (RLS)
Legislation
   o The Data Protection Act 1998 London: Office of Public Sector Information.
     Available at: www.opsi.gov.uk
   o Freedom of Information Act 2000 London: Office of Public Sector Information.
     Available at: www.opsi.gov.uk

Care Quality Commission
   o CQC A new system of registration: Notifications required by the Health and
     Social Care Act 2008 - Guidance for NHS providers




 Incident Reporting and Management – Version 4 (17/5/10)   Page 38 of 95
                                                                                    Appendix A
Equality Impact Assessment Tool
To be completed and attached to any policy document when submitted to the Executive Management
Team for consideration and approval.
    Equality Impact Assessment             Evidence based Answers & Actions:
    Questions:
1   Name of the policy that you are        Incident Reporting and Management (including
    Equality Impact Assessing              Serious Untoward Incidents)
2   Describe the overall aim of your       The overall aim of the policy is to describe the
    policy and context?                    Trust‟s approach to reporting & managing incidents
    Who will benefit from this             All staff
    policy?
3   Who is the overall lead for this       Director of Nursing Compliance and Innovation
    assessment?
4   Who else was involved in               Incident Management Support - team leader
    conducting this assessment?            Senior Portfolio Manager Risk
5   Have you involved and                  Yes – a range of Trust groups and individual staff
    consulted service users, carers,       were consulted during the original development of
    and staff in developing this           the Policy
    policy?
    What did you find out and how          Inclusions and amendments made where necessary
    have you used this information?
6   What equality data have you            N/A
    used to inform this equality
    impact assessment?
7   What does this data say?               N/A
8   Have you considered the
    potential for unlawful direct or       Yes
    indirect discrimination in
    relation to this policy?
9   Taking into account the                Where Negative impact has been identified
    information gathered does this         please explain what action you will take to
    policy affect one group less or        mitigate this. If no action is to be taken please
    more favourably than another           explain your reasoning.
    on the basis of:
                                           YES      NO
    Race                                             N

    Disability                                       N

    Gender                                           N

    Age                                              N

    Sexual Orientation                               N

    Religion or Belief                               N

    Transgender                                      N




 Incident Reporting and Management – Version 4 (17/5/10)            Page 39 of 95
10   What measures are you                     This policy aims to standardise the approach to
     implementing or already have in           incident management and reporting and exclude any
     place to ensure that this policy:         potential discrimination or bias
        promotes equality of
           opportunity,
        promotes good relations
           between different equality
           groups,
        eliminates harassment and
           discrimination
11   Have you developed an Action
     Plan arising from this                    N/A
     assessment?
     If yes, then please attach any
     plans at the back of this
     template
12   Who will approve this                     Executive Management Team
     assessment and when will you              When revised policy is approved by Trust Board
     publish this assessment.


If you have identified a potential discriminatory impact of this policy, please refer it to the Director of
Corporate Development or Head of Involvement and Inclusion together with any suggestions as to the
action required to avoid/reduce this impact. For advice in respect of answering the above questions,
please contact the Director of Corporate Development or Head of Involvement and Inclusion.




 Incident Reporting and Management – Version 4 (17/5/10)                   Page 40 of 95
                                                                                     Appendix B

      Checklist for the review and approval of Procedural Document
               Incident Reporting and Management - policy and procedure

To be completed and attached to any policy document when submitted to EMT for consideration and
approval.
                                                          Yes/No/
       Title of document being reviewed:                                   Comments
                                                          Unsure
 1.    Title

       Is the title clear and unambiguous?                 YES

       Is it clear whether the document is a guideline,    YES
       policy, protocol or standard?
 2.    Rationale

       Are reasons for development of the document         YES
       stated?
 3.    Development Process

       Is the method described in brief?                   YES
       Are people involved in the development              YES
       identified?

       Do you feel a reasonable attempt has been           YES
       made to ensure relevant expertise has been
       used?

       Is there evidence of consultation with              YES
       stakeholders and users?

 4.    Content

       Is the objective of the document clear?             YES

       Is the target population clear and                  YES
       unambiguous?

       Are the intended outcomes described?                YES

       Are the statements clear and unambiguous?           YES

 5.    Evidence Base

       Is the type of evidence to support the              YES
       document identified explicitly?
       Are key references cited?                           YES

       Are the references cited in full?                   YES
       Are supporting documents referenced?                YES

 6.    Approval

       Does the document identify which                    YES
       committee/group will approve it?
       If appropriate have the joint Human
       Resources/staff side committee (or equivalent)

 Incident Reporting and Management – Version 4 (17/5/10)             Page 41 of 95
                                                           Yes/No/
      Title of document being reviewed:                                    Comments
                                                           Unsure
      approved the document?

7.    Dissemination and Implementation

      Is there an outline/plan to identify how this will    YES
      be done?
      Does the plan include the necessary                   YES
      training/support to ensure compliance?
8.    Document Control

      Does the document identify where it will be           YES
      held?

      Have archiving arrangements for superseded            YES
      documents been addressed?
9.    Process to Monitor Compliance and
      Effectiveness

      Are there measurable standards or KPIs to             YES
      support the monitoring of compliance with and
      effectiveness of the document?

      Is there a plan to review or audit compliance         YES
      with the document?
10.   Review Date

      Is the review date identified?                        YES

      Is the frequency of review identified? If so is it    YES
      acceptable?
11.   Overall Responsibility for the Document

      Is it clear who will be responsible                   YES
      implementation and review of the document?




Incident Reporting and Management – Version 4 (17/5/10)              Page 42 of 95
                                                                                            Appendix C

                                    Version Control Sheet

               Incident Reporting and Management - policy and procedure

This sheet should provide a history of previous versions of the policy and changes made
 Version      Date             Author             Status                Comment / changes
 3          Oct        and Helen Roberts      Final       Developed from previous Incident
            2008                              draft for   management and SUI policies and
                                              approval    procedures
 4          May        Updated by Helen       Final       Updated from previous version dated Oct
            2010       Roberts and Linda      draft for   2008
                       Hollingworth           approval




Page 43 of 95
                                                                                              Appendix D
Guidance on completing an Incident Report Form (IRF) -
electronic or paper
Staff must complete an Incident Report Form (IRF) – paper or electronically as soon as possible after
an incident. (Staff must only use the Datixweb IRF when their team/unit manager has received
training. If in doubt, please check prior to reporting.)

For help with completing Incident Report Forms (IRFs) contact the Incident Management
Support Team (Tel: 01422 281334 or e mail risk@swyt.nhs.uk) or refer to the Incident
Management pages on the Trust intranet for the Incident Reporting and Management Policy and
Procedures:
  Paper IRFs must be completed in black ink using print not script handwriting. Any
     incomplete/incomprehensible forms will be returned to the team/unit manager.
  All relevant sections (on paper or electronic forms) must be fully completed with as much detail
     as possible (on Datixweb these are mandatory fields, marked with an asterisk). This information
     includes:

Incident Details
Where did the        Location of the incident i.e. hospital, patient‟s home, community team base etc.
incident occur       Include Exact location if known i.e. bedroom, kitchen etc.
When did it          Date – either when it occurred, or if not known, when it was first known about .
happen               Include the time if known (24 hour format)

What type of         Select relevant option from the list on the Incident report form.
Incident
Description of       Description section - describe the incident in as much detail as possible. Ensure
what happened        that the information provided is factual and not opinion.

Actions taken        Describe all actions taken to limit harm/damage and prevent recurrence, such as:
                     □ Ways in which the risk was managed or controlled.
                     □ Any preventative measures or procedural changes.
                     □ Contact with family members, carers or external agencies such as the Police.
                     □ Advice/contact from specialist advisors e.g. Moving and Handling, Health &
                        Safety
Clinical Actions     Select any of the options from the list to record any specific clinical actions/
                     interventions that were taken as a result of the clinical incident. Select as many as
                     necessary. This enables reports to be produced on the outcome of incidents.
People Informed      Select the relevant options to record who has been notified about the incident
Severity or risk     Select a severity grade appropriate to the incident. This is based on your
grading              assessment of its severity. Managers will review the severity during the approval
                     process.
Result/Outcome       Indicate whether the event was an actual incident (whether resulting in
                     injury/harm or not) or a near miss.

People involved in the incident:–
Complete all sections for everyone involved in the incident
     All names should be entered in full and not abbreviated (i.e. Andrew not Andy, Elizabeth not
       Liz). (Please refer to health records for correct spellings)
     The spelling of names should be checked before entering.
Person affected        Enter details of the person affected by the incident, in line with above
by the incident        guidance. If there is more than one person affected by this incident, include
                       details of all parties.
                     Injuries: Tick the appropriate box if injuries or harm have occurred:
                          □ What type of injury(s) was sustained
                          □ Which area of the body was affected
                          □ What treatment was required

Page 44 of 95
Person alleged to    Enter details of person alleged to be responsible for causing the incident, in
have been            line with above guidance. If there is more than one witness to the incident,
responsible for      include details of all parties.
the incident         Please note, this information is recorded to assist with establishing patterns/
                     trends rather than to apportion blame.
Witnesses            Give details of any other person(s) who was involved in or witnessed the incident.
                     If there is more than one witness to the incident, include details of all
                     parties.

                     Witness statements may be required. See guidance in Appendix S.
Reporter             Enter details of person completing the form

                     Paper IRFs should then be passed to the manager (supervisor/team
                     leader/manager) for approval.
                     Electronic IRFs should be „submitted‟ on datixweb. The appropriate manager(s)
                     will then be alerted automatically by email notification.

Recording Incidents when more than one person has been affected
When an incident occurs that results in more than one person being injured (staff, patients or
visitors), the person in charge of the unit or ward will need to ensure that:
      Only one incident is entered on Datix to ensure accurate data is maintained. Where
        several people may be affected or injured during an incident and their details and injuries
        can be recorded on one incident record.
      The main member of staff involved or witnessing the incident should complete an incident
        form describing clearly what happened, but they should refer to all other members of staff
        involved on the form.
      Ensure any other related incident report forms are cross referenced to each other with their
        IRF numbers
      Further guidance can be provided by Incident Management Support Team, including
        removing any errors or duplicate records.

Serious Untoward Incidents (incidents graded red)
If an incident is graded red it is could potentially be classed as a Serious Untoward Incident. It is
important that the Unit/Team or Department Manager is contacted immediately to ensure that the
situation is managed appropriately. The Unit/Team or Department Manager must verbally brief
the appropriate senior manager, and Incident Management Support Team as soon as it is
possible, in line with Trust‟s Serious Untoward Incident procedures. This is because all Serious
Untoward Incidents need to be reported to the Strategic Health Authority within 24 hours.

Paper IRFs - A copy of the IRF must be faxed to the General Manager within 12 hours.

Electronic IRFs - an email alert will be automatically sent to senior managers where the severity
is amber or red. Upon submission of a Datixweb incident report form, a list will appear noting
which senior managers have been informed of the incident by email alert. Please inform any other
managers necessary.

Replacement Incident Report Form books
Please contact the Facilities Department at Fieldhead on 01924 327496 for a replacement

Datixweb – contingency
Managers should ensure that a paper Incident Report Form book is retained in the unit/team/
department in the event that Datixweb is unavailable. Information on the incident should be
recorded on the paper form as a temporary measure, until the system is operational again. When
this occurs, data should be entered onto Datixweb incident report form asap by the reporter. It will
then be processed as normal.




Page 45 of 95
                                                                                 Appendix E

Incident Report Forms (IRF) – manager’s guidance
This guidance provides a checklist for managers approving electronic and paper Incident
Report Forms (IRFs).

Overview
Once an IRF has been completed (electronic or paper), the incident must be reviewed and
approved by the responsible manager.

Ideally this initial review should occur within 72 hours of the incident being reported. For
paper forms this is to ensure that data can be entered on Datix within seven days of the
incident being reported. Incidents reported on Datixweb are effectively already on Datix,
and should be reviewed by the manager within seven days. Please note that serious
incidents (amber and red) should be processed and reviewed within 24-48 hours.

Managers must ensure they have cover arrangement in place so this process continues in
the event of sickness and absence. This applies to both paper reporting and electronic
reporting via Datixweb.

It is important that IRFs are processed in a timely manner to ensure that accurate
information about incidents is available on Datix promptly, to avoid any inaccuracies in the
number of incidents occurring.

Manager responsibilities
The manager of each unit, team or department is responsible for:
    ensuring that an IRF is completed for all incidents in their area of responsibility
     (either electronically or on a paper IRF)
    ensuring that each incident is reviewed to ensure the information recorded meets
     the trust standards and that it is then approved
    ensuring that appropriate actions are implemented to prevent recurrence
    alerting senior managers to serious and significant incidents (this will be automatic
     via Datixweb) but should be followed up verbally
    Giving feedback on the outcome of incidents to staff (individuals and/or team)
    Ensuring the appropriate level of investigation/review is undertaken, dependent
     upon the grade.
    Reviewing incident data at a local level to ensure issues and themes are identified,
     acted upon and lessons learnt are shared

General points to consider when reviewing an IRF
Managers should only approve an incident when they are confident that the following
points have been reviewed:

Incident description and details
    Information provided should follow the principles of clinical documentation
      standards i.e. documentation should be defensible
    Is the information accurate and does it provide a full account of the event?
    Is the information provided on the form factual and not opinion?
    Is the grading appropriate? If necessary the grading can be amended, however
      this should be done in consultation with the staff member to ensure the reasons are
      explained further. (Please note that on Datixweb, a change of grading to a higher


Page 46 of 95
       level will NOT result in an email alert being sent to senior managers, they will need
       to be alerted separately)
      Does it contain any abbreviations? Are these explained in full?
      For paper IRFs, is it legible and written in black ink?
      For electronic IRFs, ensure the description and action taken fields are anonymous
       and have no person identifiable information for staff or service users, to ensure the
       Data Protection Act is not breached.
      Are all relevant sections are completed? (if there is missing information on paper
       forms, the form cannot be entered on Datix and will be returned)

Actions taken and learning to prevent recurrence and reduce risk:
    It is essential that all actions taken following the incident are recorded on the form
      in full, however minor. If an action is not recorded, there is no evidence that it was
      carried out in the future.
    Ensure that the actions identified on the IRF are appropriate
    Ensure that ALL the actions taken have actually been recorded, and add any that
      haven‟t
    Are there any wider issues that need to be considered? e.g. child at risk,
      allegations of abuse, reporting to the police
    Do you need to inform or get advice from a Trust specialist advisor, e.g.
      safeguarding children, vulnerable adults, moving and handling, security, infection
      control, health and safety, fire, control and restraint, pharmacist etc. Record any
      details
    Is the incident RIDDOR reportable? If so report to Health and Safety Advisor and
      record on form
    Is the incident a patient safety issue? Please indicate this on the form
    Record what clinical interventions have been used to manage the incident, eg use
      of medication, physical interventions and seclusion. Please indicate them on the
      form
    If an incident requires Facilities Department action, please report this through the
      usual procedure (e.g. Facilities Hotline). Please record the job number on the IRF.
    Ensure appropriate level of investigation/review is undertaken

Recording Incidents when more than one person has been affected
When an incident occurs that results in more than one person being injured (staff,
patients, visitors or department), the person in charge of the unit or ward will need to
ensure that:
    Only one incident is entered on Datix to ensure accurate data is maintained.
    Where several people are affected or injured during an incident, their details and
       injuries can be recorded on one incident record.
    The main member of staff involved or witnessing the incident should complete an
       incident form describing clearly what happened, but they should refer to all other
       members of staff involved on the form.
    Ensure any other related incident report forms are cross referenced to each other
       with their form numbers
    Managers can „reject‟ an incident on Datixweb if they are confident it has been
       reported previously. They will be asked to explain the reason for the rejection.
       IMST will review all incidents that are rejected.
    Further guidance can be provided by the Incident Management Support Team,
       including removing any errors or duplicate records.



Page 47 of 95
Serious Incidents
    For red graded incidents, complete the Management Fact Find Report in line with
      the guidance on managing and reporting Serious Untoward Incident in Section 7.
    For amber graded incidents and service user deaths, ensure that the general
      manager is made aware and complete the Management Fact Find Report

Amendments to Incident Report Forms
   Managers should be aware that any amendment to an incident record on Datixweb
    will be logged and a full audit trail is retained, with details of who made the change
    and when). The original IRF will be retrievable.
   On paper IRFs, there is a separate section for manager amendments.
   If an IRF is incorrectly/poorly completed, the manager should discuss this further
    with the person who completed the form and provide support and guidance to
    ensure IRFs are completed correctly in future.

Re-grading
It may be necessary for an incident to be re-graded at some point after it has been
reported, as more information becomes available. Managers using Datixweb can change
the grading, however, they should alert the service manager and the Incident
Management Support Team to the change. Managers using paper forms should contact
the IMST to make an amendment to the grading.

Paper IRFs (also see Appendix Q: record keeping following an incident)
In areas using paper IRFs, the completed IRF must be given or sent to the designated
person in the service area for entry onto Datix. The designated person will be identified
locally.

It is the responsibility of the manager to ensure that a copy of any completed paper IRF is
retained in the ward/team/dept for future reference. This is not necessary for Datixweb
entries as the database is also an archive and can be accessed by the manager. In the
event of litigation claim, an original paper IRF (or a copy from Datixweb) may be needed
as evidence.

An IRF does not form part of a service user‟s healthcare record, and therefore a copy
should be kept in a separate Trust file. An entry should be made in service users‟
healthcare record that an incident has occurred, including a note of the IRF reference
number. (Any documents held in a service users healthcare records will become a
disclosable document in any legal process. IRFs may also contain information about other
parties.)

If a paper IRF is spoiled, either through incorrect information, damage, etc, please send
the form to the Incident Support Team (Dean Clough).




Page 48 of 95
                                                                                 Appendix F

Datix and Datixweb – electronic risk management database and
electronic reporting
1. Overview
The Trust uses an electronic risk management database (Datix) to record all incidents
reported in the Trust on electronic or paper Incident Report Forms (IRFs). Datix is also
used to record and manage other risk information such as complaints, claims and
inquests. Related issues can be linked together on Datix, such as an incident, and a
related complaint and claim.

An individual incident record is created on Datix for each incident, where the incident
details are recorded. Each incident is defined by person and service information, and by
severity, type, category and sub category. This incident data is extracted from Datix in
various formats and presented in reports to enable further analysis. Reports are reviewed
at various Trust groups so that we can improve systems and processes across the Trust,
reduce risk and improve safety for patients and staff. All patient safety incidents entered
on Datix are uploaded to the National Patient Safety Agency (NPSA) National Reporting
and Learning System (NRLS) on a regular basis.

2. Datixweb – Electronic Incident Report Forms (IRFs)
Datixweb is an electronic incident reporting system which will largely replace the use of
paper IRFs. This system facilitates quicker incident reporting. The Incident Management
Support Team train key staff in using datixweb and provide ongoing support in line with
this document.

Electronically completed IRFs are „submitted‟ onto the Datixweb system and automatically
emailed to the designated manager. Managers are alerted to new incidents by email, and
prompted to review and approve incidents electronically. Once approved, incident report
forms move directly into the incident database (Datix). Managers are able to access all the
incident information relating to their area of responsibility directly on DatixWeb, review
local incidents to maintain an overview of incidents in their area of responsibility, identify
any issues and produce reports. Service managers can also access Datixweb to approve
incidents in the event of absence and allow for any management issues to be identified
and resolved.

3. Incident data quality audit
The IMST carry out regular random audits of data quality on Datix to ensure that incident
data is as accurate as possible and is compliant with the NPSA NRLS data quality
standards (2009). Any data quality issues identified during the audit process will be
resolved with the responsible manager and if necessary further training provided. The
audit process ensures that:
    Relevant fields are completed and information is in the correct fields
    Data is entered consistently across the service
    Description and action taken fields do not contain person identifiable information
    Description of the incident is „coded‟ correctly, and in the appropriate categories
    Severity is appropriate to the description of the incident
    Links to other modules are correct eg contacts, to avoid duplicate records
    Inputting delays are identified and flagged up to the appropriate manager
    Potentially externally reportable incidents are alerted appropriately



Page 49 of 95
                                                                                 Appendix G
                Grading Incidents using the Risk Grading Matrix
1. Introduction: the Risk Grading Matrix
Incidents that occur within the Trust will have different levels of impact or severity. To
enable us to understand the severity and priority of an incident all incidents are graded in
line with the Risk Grading Matrix developed by the Trust (below). The matrix is described
more fully in the Trust‟s Risk Management Strategy.
This Risk Grading Matrix enables staff to severity/risk grade incidents by colour (green,
yellow, amber or red).
       Green - incidents are the least serious and that have the least impact
       Red – most serious incidents or have the greatest impact




2. Why grade incident severity? - grading incident severity enables us to:
 o Understand the priority and level of response and investigation that is needed. Not all
   incidents will need to be investigated or responded to with the same depth or extent.
   The colour (risk category) will determine the level of investigation/analysis required.
 o Analyse and compare the severity of the incidents to recognise and learn from trends
   or patterns in the adverse incidents being reported.
The matrix has two dimensions:



Page 50 of 95
       Likelihood:          how likely it is that the incident could happen/could happen
                            again (if nothing is done to prevent it)
       Impact:              the actual impact or outcome of an incident (the potential
                            impact or outcome for a near miss)
In grading incidents the main dimension to consider and use is the impact or outcome of
the incident, with some consideration of the likelihood of recurrence.




3. Grading an incident
It is impossible to give a definitive guide to the grading of incidents because each incident
will be affected by a number of variables, such as individual, clinical, environmental and
other risk factors. Some examples of possible grading as a guide include:
       Green
             –    An minor accident which did not cause any injury
             –    A prescription card was temporarily misfiled
       Yellow
             –    an accident which led to a minor injury such as bruising
             –    a drug error which did not cause any harm
             –    notes temporarily unavailable for an assessment
       Amber
             –    a drug error which could happen again and which led to minor harm
             –    patient took serious overdose but fully recovered
             –    garden/work tools (pick axe and saw) found in the garden of an acute
                  inpatient unit (had been left overnight by workmen).
       Red
               – Death of a service user – suspected suicide
               – A drug error which has caused serious harm
               – A member of staff dismissed following a disciplinary investigation and
                 hearing

Staff reporting an incident should grade adverse incidents immediately and record this on
the Incident Report Form as they complete the form. This initial grading will be based on
the individual‟s professional and personal judgment of the impact and severity of the
incident. It is not necessary at this stage to have all the facts surrounding the incident. The
grade can be reviewed and adjusted as further information and facts become known.
Any adjustments to the grading made by the manager who reviews the incident report
form will be done in consultation with the staff member who reported the incident.

Page 51 of 95
When grading staff should take into account:
          o The actual harm or outcome
          o The potential harm or outcome (for a near miss incident)
          o The likelihood that this incident or near miss could happen again

Re-grading incidents
During the course of an incident being reviewed or investigated, it may be necessary for
the incident to be re-graded as more information becomes available. It is the responsibility
of the Service Manager to liaise with the Incident Management Support Team accordingly.
Details of revised grading and the reasons behind this decision will be required for
recording on Datix, the Trust‟s electronic risk management system.

Grading allegations
Sometimes an allegation is made that something has happened, been done or not been
done, where only an investigation will clarify if the allegation is true. An Incident Report
Form will be completed and the incident initially graded as if the allegation were true. The
grading can then be adjusted according to the outcome of any investigation and/or
disciplinary hearing – contact the Incident Management Support Team risk@swyt.nhs.uk.
If a member of staff is dismissed following a disciplinary process (where the event related
to patient safety) this will be recorded as a Serious Untoward Incident, graded red and the
SHA informed. Although a disciplinary investigation will already have been completed a
summary report and action plan to implement any learning may be appropriate.
4. Red incidents or Serious Untoward Incidents (SUI)
These are the most serious and significant incidents, which can include some near
misses. It includes incidents that had very serious consequences, such as serious injury
or death of a service user, staff member or visitor. In very simple terms a red incident is a
SUI, and a SUI is a red incident. (Examples and guidelines of what would be considered
to be red or Serious Untoward Incident are given in Appendix L. Appendix V gives the
Department of Health guidance on grading incidents involving data loss and confidentiality
breaches.)
These are therefore managed with care and consideration within the Trust, both at the
time of the incident and afterwards. Section 7 of this document describes the procedures
to be followed in the event of a Serious Untoward Incident.

The grading potential red incidents, which will be managed as Serious Untoward Incidents
(SUIs) will be confirmed by the responsible Director or nominated deputy following the
Management Fact Find process.




Page 52 of 95
                                                                                 Appendix H
Examples of reportable incidents
An incident is an unintended and/or unexpected event or a circumstance that actually led
to, or could have led to harm, loss or damage to a service user, a member of staff, a
visitor/contractor or to property (see definitions in Appendix X).

The following are examples of types and categories of incidents that should be reported.
The lists are by no means exhaustive and any incident or event that gives rise for concern
should be reported. If in any doubt about whether something should be reported or not,
please discuss with your line manager or contact the Incident Management Support Team
for further advice.

Incidents involving individual service users
Incidents relating to service users and clinical care will be recorded on an Incident Report
Form (IRF) – electronic or paper based. These incidents will be categorised as one of the
„incident types‟ listed below.

Incidents affecting service users will also be recorded in the individual healthcare records
with a note of the Incident Report Form reference number. Care should be taken to
respect confidentiality by not including identifiable information about other service users or
third parties in healthcare records. Incidents should also be considered for discussion in
care review meetings, and care plans amended as necessary. The review process, or
rationale for not needing further review following the incident, should also be recorded in
the case notes.

Incident types
This is a list of the main incident types listed on the IRF which are used to categorise
incidents on Datix:
       1 Health and Safety (including accidents, fire and security incidents)
       2 Missing/absent service users
       3 Slips trips and falls incidents
       4 Care pathway and clinical incidents (including incidents relating to admission,
            discharge, transfer, communication)
       5 Child Protection incidents
       6 Violence and Aggression incidents
       7 Information governance: Confidentiality, Health Records, IT incidents
       8 Self Harm incidents
       9 Legislation and Policy e.g. MHA, Trust Policies, illegal acts
       10 Death of Service users (including suicide)
       11 Medication incidents
       12 Other incidents

1. Health and Safety (including accidents, fire and security incidents)
Trust Specialist Advisors (See Appendix T) can give advice on reporting this type of
incident. Examples of the sort of incidents that would be reported under this type are:
     Accidental injury
     Contact with or exposure to hazards
     Infection control breaches
     Work environment hazards
     Fires and fire alarms including false alarms
     Moving and handling

Page 53 of 95
      Medical devices and equipment
      Vehicle incidents, e.g. Road Traffic Accidents
Security incidents include any incident that involved theft, loss or damage to
organisation or personal property, such as:
    Deliberate damage to equipment, property and vehicles
    Theft (or alleged) of equipment, property and vehicles
    Intruder alarms including false alarms
    Breaches of security
    Security threats and scares
Infection control incidents: the Health and Social Care Act 2008 includes a code of
practice for the prevention and control of infections. New laws about notifying infectious
diseases will be introduced in 2010. The code requires that Chief executives of NHS trusts
report cases and outbreaks of certain infections to the Health Protection Agency (HPA).
The relevant infections are:
     Clostridium difficile
     Blood stream infections caused by meticillin resistant Staphylococcus aureus
       (MRSA) and glycopeptide resistant entrococci (GRE)
The code of practice also requires that the Trust (as a registered provider) reports
significant outbreaks of infection to the HPA if advised to do so by a suitably informed
medical practitioner. NHS organisations should report relevant outbreaks as serious
untoward incidents (to the PCT and NPSA.
Health and Safety (including accidents, fire and security) incident data is reviewed at the
Health and Safety Trust Action Group and the clinical service management group.

Guidance on investigating health and safety incidents, accidents and near misses can be
found in the Investigations document.

2. Missing/Absent service user
Some examples of the sort of incidents that would be reported under this type are:
    Patient absconds from staff on escorted leave
    ward/services without permission
    Patient escapes from unit/hospital
    Patient attempted to leave unit
    Patient failed to return from ground leave

3. Slips trips and falls
Examples of the sort of incidents that would be reported under this type are:
     Slips, trips and falls by service users
     Slips, trips and falls by staff members and visitors
     Codes also cover whether a fall was on a level surface, stairs, from height, on ice
Further guidance on reporting this type of incident can be sought from the relevant Trust
Specialist Advisor (See Appendix T).

4. Care pathway and clinical incidents
Examples of the sort of incidents that would be reported under this type are:
     Admission and discharge problems
     Problems with service users leave arrangements
     Service user failed to return from authorised leave
     Transfer of service user

Page 54 of 95
      Communication problems
Further guidance on reporting this type of incident can be sought from the relevant Trust
Specialist Advisor (See Appendix T).

5. Child protection (safeguarding)
Staff should report and record any incident where a child has been affected or where
there is concern for the wellbeing of a child.
Examples of incidents falling with this type would include issues or concerns around:
    Physical abuse of a child
    Neglect
    Emotional abuse
    Admission of an under 18
    Children visiting a Adult Mental Health unit
    Admission of a child to an Adult Mental Health unit

6. Violence and aggression incidents
Staff should report and record all incidents of violence, aggression and assault. This will
include recording all action taken to manage the situation such as the use of rapid
tranquillisation, physical intervention or seclusion. Examples of incidents falling within this
type of incident would include:
     Aggressive behaviour
     Allegations
     Physical Assaults
     Abuse of vulnerable adults
     Verbal Abuse
     Homicide
     Harassment, including sexual and racial
     Inappropriate behaviour including sexual
     Sexual assault
Definition of assault, as given in Directions to Tackle Work on Violence, November 2003,
       “the intentional application of force to the person of another without lawful
       justification, resulting in physical injury or personal discomfort”
Where members of staff are physically assaulted, this should be discussed with line
managers and, where appropriate, staff members are encouraged to involve the police.
Staff who observe abuse or who have a concern in relation to abuse or violence towards a
service user will report this to their line manager as soon as possible to ensure that the
Safeguarding Vulnerable Adults Protocol is followed. If for any reason a staff member
suspects that their line manager may be implicated, a more senior manager will be
informed. An Incident Report Form will also be completed stating the actions that have
been taken.
Further guidance on reporting this type of incident can be sought from the Trust„s
Vulnerable Adults Specialist Advisor, the Management of Violence and Aggression
Advisors and the Local Security Management Specialist. (See Appendix T).
Incident data relating to Violence Aggression and Assault incidents is reviewed at the
Managing Violence and Aggression Trust Action Group and the Health and Safety Trust
Action Group.


Page 55 of 95
7. Information governance: confidentiality breach, health records and information
technology (IT) incidents
This type of incident includes any incidents or events where there has been an issue or
concern with information and records, including healthcare and other records. The Trust
uses and documents information for a wide variety of reasons including communication
and retaining contemporaneous records. It is important that this information is accurate,
accessible and that the confidentiality of services users and staff is appropriately
protected. Incident data relating to Confidentiality, Health Records and IT incidents is
reviewed at the Information Governance Trust Action Group and risk sub group. Examples
of these incidents are:
     Unauthorised or inappropriate disclosure of confidential service user information,
       (accidental or deliberate).
     Unavailability of healthcare records
     Missing or destroyed healthcare records
     Inaccurate information
     Breach of computer password security
     Loss or damage to Human Resources records
     Disclosure of staff information, accidental or deliberate
Examples of reportable IT incidents are:
   1. IT system failures
   2. Network / system security
   3. computer viruses
   4. Loss of electronic data
   5. Unauthorised access or misuse of IT systems
   6. Inappropriate use of IT and Internet facilities, e.g. accessing pornographic/obscene
      material
Advice on these incidents (see Appendix T) can be obtained from the:
      o Health records and information governance portfolio manager.
      o IT Service Desk which provides an IT support service to all Trust staff. Calls are
         logged when there are problems or failures reported by IT users. They will also
         advise staff whether or not an Incident Report Form needs to be completed.
      o Incident Management Support Team
      o Appendix V – Department of Health guidance on grading and reporting
         incidents relating to loss of data and confidentiality breaches.

8. Self harm incidents
Examples of incidents of this type include:
     Actual Self Harm
     Alleged/Suspected Self Harm
     Attempted Self Harm
     Attempted Suicide
Further advice on whether an event should be reported as an incident can be obtained
from the Incident Management Support Team or through line management arrangements.
(See Appendix T for contact details).
Incident data relating to Self Harm Incidents are reviewed by each clinical service
management group.

9. Legislation and Policy e.g. Mental Health Act, Trust Policy breaches, illegal acts
These incidents include:
     Locking doors on open wards

Page 56 of 95
      Invalid detention (e.g. MHA section expired)
      Incorrect section paperwork
      Failure to carry out observations
      Breach of the No Smoking policy
      Illegal acts
      Use of illegal substances/drugs on Trust premises
Further advice on whether an event should be reported as an incident can be obtained
from the Incident Management Support Team.
MHA incidents will be reviewed at the Mental Health Act Committee. Other incidents will
be reviewed at the clinical service management groups.

10. Death of Service user (including suicide)
There are many reasons why someone who is receiving care from the Trust could die,
and this may or may not be a serious incident. Because the cause of death may initially be
unclear, any unexpected death of a current or recent service user (within the last 6
months), will initially be treated as a serious incident (amber or red) and both an Incident
Report Form and Management Fact Find Report completed (see Appendix K). These
will include:
     Suspected Suicide
     Undetermined Death
Data relating to service user deaths is reviewed by the service management group.

11. Medication incidents
Incidents reported under the type of Medication incidents include:
     Prescribing errors
     Administering errors
     Dispensing errors
     Procedural errors
     Including wrong drug, incorrect dosage, incorrect time administered, contra
       indications to drug not assessed etc)
     Adverse reaction to medicines (may also require external notification to the
       Medicines & Healthcare Product Regulatory Agency, MHRA)
Further advice on whether an event should be reported as a medication incident can be
obtained from the Pharmacy Department or alternatively contact the IMST.

12. Other Incidents
Wherever possible, incidents should be included as one of the above types. However
these lists are not exhaustive and sometimes an incident will occur that does not apply to
these types and included as „other‟. Examples of might include:
    Financial loss
    Illegal or unauthorised acts
    Staffing issues
    Staff becoming unwell during working hours
    Illness of service users
    Non violent/aggressive inappropriate behaviour of service user
These incidents will be reviewed by the Incident Management Support Team, placed with
an appropriate group and the current incident categories or types reviewed to ensure that
information about incidents is being collected effectively.


Page 57 of 95
                                                                                Appendix I

Examples of Serious Untoward Incidents (SUI) – all red incidents
Incidents or adverse events graded red and need to be reported as an SUI via the D of H
electronic SUI reporting system (STEIS/SIMS). This list is not exhaustive or in order of
importance. If in doubt, report immediately and discuss with the relevant senior manager,
Director or the Incident Management Support Team.

 Death or serious injury to a patient or member of the public which is alleged to be at
  the hands of another patient or member of the public while on NHS premises
 Suspected homicide by a person currently in receipt of mental health services (or
  within the last six months)
 Suicide of a person currently in receipt of NHS mental health services (out-patients &
  in-patients) or who have received NHS mental health services in the last 6 months
 Serious injury of a person currently in receipt of NHS care (or within the last six
  months) as a result of deliberate self-harm (eg attempted suicide) or accidental injury
 Patients detained under the Mental Health Act who abscond from NHS care and who
  present a serious risk to themselves and/or others, particularly patients who abscond
  from medium secure or specialist forensic services, those who are likely to pose a risk
  to the public, attract media attention and/or who commit an offence in the community
 Death or serious injury to a child which results in a „serious case‟ review under the
  Children's Act 1989, where health has played a major role
 Death or serious injury to a member of staff (including independent contractors e.g.
  GPs, dentists, opticians, pharmacists) in the course of their NHS duties
 Medication incidents resulting in death/serious injury eg incorrect medication
  dispensed to patient; drugs given to patients with known allergy
 Failure of medical equipment resulting in death/major injury
 Clinical incidents resulting in death/serious injury eg medication error etc
 Serious fires or other serious damage, which occurs on NHS/Independent contractor
  premises, particularly a fire which results in casualties or major disruption to services
 Serious or unexplained outbreaks of infection or disease in hospital (eg food poisoning,
  Legionnaire‟s Disease) or the confirmed transmission of serious infectious disease
  between an NHS staff member and a patient (eg HIV/Hepatitis B)
 Major system failure e.g. failure of laboratory services to provide accurate screening
  results; patient referral system failure for further consultation/treatment
 Major environmental incident (e.g. release of gas/chemicals, inappropriate disposal of
  clinical waste) which has or could have harmed the public
 Major service disruption e.g. due to power failure, flooding, etc
 Major breach of patient confidentiality or loss of personal data eg theft of patient notes
  or computers/ laptops containing patient information; discovery of patient records in
  public area (see Appendices U and V)
 Incidents/concerns regarding NHS staff (including independent contractors) eg fraud,
  gross misconduct and actions resulting in harm to patients which could lead to
  suspension/ dismissal, media interest and/or involvement of the criminal justice system
 A pattern emerging that is causing concern such as a high number of complaints
  regarding a member of staff (including independent contractors), a particular service
  and/or hospital that may warrant further investigation and action.




Page 58 of 95
                                                                                    Appendix J
          Flowchart for reporting Amber and Red incidents
                             Possible red incidents –
         AMBER             initially grade at amber but            RED
                                 timescales as red


   IRF completed asap                                     IRF completed asap


  IRF to GM in 24hrs &                               IRF to GM within 12 hrs &
    on Datix in 3 days                                     Datix in 24hrs


 Management Fact Finding                              Management Fact Finding
   Report completed by                               Report completed by general
general manager within 48                             manager within 24-48 hrs &
hrs & emailed to AD & IMST                              emailed to AD & IMST



                        Discussion between GM, AD &
                        Director to review information
                             and confirm grading

                                 Grading
                AMBER           confirmed                 RED


  No further               Issues for                     Reporting to SHA by IMST
investigation                further
   required              investigation
                           Identified.            GM and AD agree:
                            Systems               - Level of RCA, review team
                         Check report               Terms of Ref. & timescales
                           produced               - Liaison/support – staff, user
                                                    &/or carers


        Action plan prepared                         Draft report completed & sent to
          and implemented.                             IMST for review (within 9 weeks)
         Copy to AD or D and
        IMST for Datix record                       Final approved report and action
                                                     plan sent to SHA/PCT by IMST
                                                                (within 12 weeks)

Page 59 of 95
                                                                                  Appendix K
             Management Fact Find Report – Version 04/10)
        Risk screening tool & checklist for actions. The manager to complete
 (electronically) within 48 hrs of a serious incident (RED or AMBER) being reported.
Section 1 – Incident Report Form details
Incident Report Form No:
Incident Report Form completed by:
Current Incident grading (severity):

Section 2 - Fact Finding Report Form completed by
Report completed by
Job Title
Team/Service
Base/location
Phone Number
Team Manager (name and job title) if different
Date report completed

Section 3 – Incident details – to be completed for all incidents
Date of Incident
Date made aware of incident (if different)
Time of Incident (hh:mm) if known
Factual description of what happened
Information will already have been provided on
the IRF – but review, expand, clarify this
Where did the incident occur – give specify
details if known?
What immediate actions have been taken to
minimise recurrence?
How did the Trust find out about the incident?
eg via media, family
Details of any injuries to the person affected

Section 4 – Incidents affecting Service Users - DO NOT enter patient identifiable information
Did the incident involve service user/s?                          If YES, complete this section
                                                                  If NO, go to next section
RiO Number (for cross referencing purposes)
GP & GP commissioning PCT area (for
reporting purposes)
MHA status and section, if applicable
Was the service user in current contact with
Trust services?
Give the date the current episode began - if in
last 3 months
If discharged from Trust services in last 6
months give date of discharge?
Date of service user‟s last actual contact with
services?
Which team/professional was the last contact
with?
Give a brief summary of his/her most recent
episode of care/contacts with mental health
services. Include a summary of clinical care
and significant events leading up to the incident
(if inpatient, include staffing levels)
Was service user an inpatient in last 3 months?
Page 60 of 95
Date of discharge from inpatient care?
What date was 7-day follow up carried out?
Was the service user on CPA or Standard
Care?
Date of last CPA review, if known
Has there been a change in clinical care in last
3 months eg change of care co-ordinator &/or
care team or service? If so give details & date
Any other relevant information

Section 5 - Immediate actions: notifying and communicating with others
Complete this section for all service users involved in the incident (eg in an alleged assault by
a patient against another patient, include information on both parties)
List all teams/services involved in the service
user‟s care & treatment at the time of the incident
– ensure that these teams/services are informed
of the incident
Give details of the service user‟s consultant
psychiatrist - ensure he/she has been informed?
Give details of anyone else (Trust or local
services) who has been informed of the incident
eg Specialist Advisors, Director, Social Services
If the incident has been reported to external
agencies, please give details
eg Police, Safeguarding, H&S Executive, others
If other agencies attended the incident scene,
give details eg police, Health & Safety Executive
If you are aware that there will be an external
investigation by another agency, give details
Give details of any known media attention
Has the Trust‟s Communication Team been
informed - if there could be media attention

Section 6 - Immediate actions – Environment
Did the incident occur on Trust property?                      If NO, go to next section
                                                               If YES, complete this section
Give details of how the environment has been
made safe eg area of unit closed, room sealed off,
transfer of patients, ligature removed
Give details of whether the incident scene has
been preserved for investigation by police or
Health & Safety Exec & if authorisation has been
given to „release‟ the incident scene by the
appropriate agency

Section 7 - Immediate actions - Equipment
Did the incident involve any Trust equipment?                  If NO, go to next section
(Eg computers, equipment, hoist, syringe, defibrillator)       If YES, complete this section
What Trust equipment was involved?
What actions have been taken to remove the
defective equipment from the scene?
Where has the removed equipment been stored?

Section 8 – Managing health care records
Did the incident involve a service user?                       If NO, go to next section
                                                               If YES, complete this section
Have all the service user‟s healthcare records
been located (including RiO, case notes;

Page 61 of 95
community team, psychology, therapy)?
If not, give details
Give details of who is holding the records?
All paper records should be retained in a central
location with a system to record requests for access.
This will usually be the service or general manager.
Has an entry been made in all records giving
details of the incident that has occurred?
If the incident involved a service users death:
 Ensure that all blank pages in paper records
     are ruled through - so that no further entries
     can be made
 Ensure that the electronic patient record is
     updated eg to state that service user has died
Copying paper records - If the service user is transferred to another trust for further treatment (eg
acute hospital) and/or if the police/Coroner are involved it is important that a copy of the Trust‟s paper
records is taken as soon as possible after the incident - in case the records are transferred/removed
(so the Trust has access to all records/information for reference eg for care and treatment or for
investigation and report writing)
    Ideally this should be carried out by the medical records department but
    The need to copy records can be out-of-hours or unexpected - so the responsible manager
       should use their discretion; it may be expedient for the local team to copy the notes
If records have been requested and/or removed
by another agency, give details

Section 9 – Death of an individual
Is the cause of death known?
If yes, give details of how we found out this
information
Give details of any other relevant information
about the death
If you are aware that the Coroner has contacted
someone in the Trust for further information or
statements, please give details
Ensure that the Trust’s Coroner liaison officer
has been informed of the death (01924 327130)

Section 10 - Supporting service users (see also Being Open policy)
Did the incident involve serious injury, harm to, or                    If NO, go to next section
death of a service user?                                                If YES, complete this section
Give details of support that has been offered to
any service users affected directly or indirectly by
the incident (including witnesses)
Ensure that all service user(s) directly affected by
the incident have been given appropriate:
     factual information about the incident
     an explanation about what happened
     an apology if necessary
     offers of support
Please give details.
If there is a member of staff who has been
identified to liaise with and support service users,
give details (Being open contact)

Section 11 - Service user’s relatives/carers (see Being Open policy)
Did the incident involve serious injury, harm to, or                   If NO, go to next section
death of a service user?                                               If YES, complete this section
Ensure that if appropriate (taking into account confidentiality and consent) the service user‟s
Page 62 of 95
family/carer has been contacted and given:
     information about the incident
     an explanation about what happened
     an apology or expression of regret
     appropriate offers of support from staff
Give details of contact with the service user‟s
family/carer following the incident including:
   - who contacted them, when and how
   - what information was given and support
      offered etc
   - the outcome and any further contact agreed
If no contact has been made, explain the reasons
why
Details of the member of staff who has been
identified to liaise with the family/carer in future

Section 12 - Staff information and support (see Supporting Staff policy)
Was the incident potentially distressing or                        If NO, go to next section
traumatic for staff eg involving the serious injury,               If YES, complete this section
harm to, or death of a service user or colleague?
Staff support needs will vary depending on the nature of the incident and the individuals involved.
Support may be needed immediately and in the longer term. Very traumatic incidents may need a
coordinated Trust approach. See Supporting Staff Policy- including flowchart and managers checklist
Ensure members of staff directly involved in the
incident have been offered appropriate
immediate support. Give details of support
offered and planned (see checklist in policy)
Ensure support is offered to the whole team as
well as individuals directly involved – give details
of support offered - including planned support
Ensure that staff in other teams and services who
may be affected are informed of the incident and
offered support. Give details
Consider the range of services that may have contact
with a service user - medical, therapy, psychology,
reception/admin staff etc

Section 13 – Incident witnesses (see Supporting Staff policy)
Were their any witnesses to the incident?                             If NO, go to next section
                                                                      If YES, complete this section
Details of witnesses (useful for investigation
purposes)
Have witness statements been provided eg by
staff on duty?
The Supporting Staff policy includes witness
statement guidance and template - or contact
Corporate Services Team on 01924 327130
If statements have been provided, provide details
of who holds the originals

Section 14 – Initial risk assessment / systems check
   An initial risk check should be carried out following a serious incident – to identifying any need for
    any immediate changes or improvements.
   Risk/systems that might need to be checked will depend on the nature and context of the
    incident.
   Information gathered and changes made at this stage contribute to any further investigation
    processes (eg a full Root Cause Analysis) and be referred to in the investigative report
   If there are emerging concerns around actions or omissions of an individual or team, this requires

Page 63 of 95
    an immediate initial discussion with the relevant senior manager/director.
Provide a summary of any risk or systems check
undertaken and the findings. Any immediate
actions required should be documented on the
attached action plan format.
Managers need to consider what they need to be
assured of in relation to processes and systems
following the incident but could include:
        - Policies and procedures in place
        - Documentation completion
        - Communication processes
        - Care planning
        - Risk Assessment
        - Staffing levels
        - Observation levels
        - Treatment/management of individuals
        - Medication

Section 15 - Next Steps
1.   Datix web users - attach the completed Fact Find Report to the incident record on datix web:
     Save the completed Management Fact Find report in folder on your network drive
     Open the relevant incident record
     Go to the „documents‟ section (left hand menu) and select „attach new document‟. You will be
      asked to select the correct document from your network drive to upload it
     Alert other colleagues (who also have permission to view the incident on datix web) to access
      the document via this route
     E mail the document (as below) to colleagues who need a copy and who do not have access to
      datix web
2.   Non datix web users
     Save & password protect Management Fact Find report in folder on your network drive
     Attach it into an e mail to colleagues who need a copy and who cannot access datix web
3.   Password Protection
     To password protect a document: when saving the document (into a shared network folder) go
      to: File, Save As, Tools, Security options – give the document a password (remember it).
     Please ring the recipient with the password – do not email it

Contact IMST risk@swyt.nhs.uk for support.




Page 64 of 95
                                                                                       Appendix L
                            Externally Reportable Incidents
Some incidents need to be reported to external agencies. An Incident Report Form (IRF)
must always be completed regardless of any external reporting. External reporting should
always be done in conjunction with the Trust responsible lead for the type of incident that
has occurred (see Appendix T). The following is a list of agencies that require some types
of incidents to be reported (see Appendix M for external stakeholder list):

    1. Serious Untoward Incident (SUI) - reporting to the commissioning PCT and
        sometimes the Strategic Health Authority (SHA)
The Trust has a responsibility to report all SUIs to the commissioning Primary Care Trust
(PCT) and sometimes the Strategic Health Authority (SHA) via the Department of Health
electronic reporting system, STEIS/SIMS (NHS Yorkshire and the Humber Procedure for
the management of Serious Untoward Incidents). This is to ensure that the PCT/SHA has
a clear picture of the numbers and types of SUIs occurring within the Trust, and so that
the Trust‟s management of the SUI can be performance managed. The PCT/SHA will
monitor and support the Trust in the management of SUIs, and where necessary act as a
link with the Department of Health (DH) and/or Care Quality Commission (CQC). The
commissioning PCT will be the usual link for the Trust regarding SUIs, and will undertake
the performance management of the process. However some more serious SUIs may still
have SHA involvement.

                    Informing commissioning PCTs of a SWYPFT SUI
                      Type of SUI                               Reporting arrangement
 SUI involving a single service user registered with    IMST will inform the relevant
 a GP in SWYPFT boundaries (or service users all        commissioning PCT via the electronic
 registered with GPs within a single PCT in the         database
 area)
 Includes staff allegations & confidentiality SUIs re   (FAO NHS C, K or W)
 service users as defined in this category above.
 SUI involving a service user of Trust Forensic         IMST will inform the relevant
 Services (subject to specialist commissioning)         commissioning PCT via the electronic
 Includes staff allegations & confidentiality SUIs re   database
 service users as defined in this category above.
                                                        (FAO NHS Barnsley (SCG))
 SUIs which involve:                                    IMST will allocate these on a „rota‟ basis
  Service user not registered with a GP in the         to NHS Calderdale, Kirklees and
    SWYPFT PCT patch                                    Wakefield in turn. The PCTs will discuss
  Service users registered with GPs in more than       any need to change this and inform
    one SWYPFT PCT area                                 SWYPFT of any changes
  Staff allegations & confidentiality re service
    users as defined in this category above.            (FAO NHS C, K or W (non
  Non-clinical incidents or clinical incidents not     commissioning allocation))
    related to specific service users
 SUI is a child protection issue                        SWYPFT will liaise inform and liaise with
                                                        the relevant PCT (probably Director to
                                                        Director + Communications to
                                                        Communications, + Child Protection to
                                                        Child protection leads). The PCT will log
                                                        the SUI and coordinate subsequent
                                                        investigation processes.



Page 65 of 95
SUIs are usually incidents graded red on the Trust‟s Risk Grading Matrix. Reporting to
the PCT/SHA is carried out by the Incident Management Support Team within 24 hours of
the incident occurring/being reported, or as soon as is practicable. A list of examples of
SUIs is available at Appendix I and also within Section 7 of this document – Reporting and
Managing SUIs Incident Procedures. Appendix M lists other potential stakeholders who
may need to be informed of and involved in SUIs.

A copy of the Trusts approved investigation report and action plan is sent to the PCT/SHA
for review and approval. Once the PCT/SHA has approved the report, the findings and
the lessons learned, the file will be closed. However sometimes further information will be
required before the file is closed.

The SHA will ensure that learning from SUIs is shared by NHS organisations in Yorkshire
and the Humber, and nationally where appropriate. The SHA have also issued a
document entitled „Good practice principles for serious incident management‟, describing
what is expected of the Trust. These principles are incorporated into this policy.

    2. Child safeguarding SUIs and other incidents – SHA, PCT and Local
       Safeguarding Boards
If a Child Protection SUI occurs the commissioning PCT will report this on STEIS/SIMS as
an SUI - regardless of which sections of local health services were involved in providing
care and treatment. The PCT will also coordinate NHS investigations and input into the
Local Safeguarding Board‟s Serious Case Review process. All potential Child
Safeguarding SUIs should be verbally reported to the commissioning PCT in the first
instance.

The relevant PCT may also have an interest in some individual incidents in relation to the
GPs involvement in providing care jointly with the Trust. In addition to informing the PCT
of SUIs the Trust will also inform the relevant PCT of any other significant incidents,
including any that attract or may attract media attention, and the PCT will be invited to be
involved in the investigation process. If a joint investigation is undertaken an agreement
will be made about who will lead the investigation.

    3. Use of Adult Psychiatric Wards for Children Under 16 – report as SUI
Any incident involving a child under 16 being admitted to an adult mental health bed
requires reporting as a Serious Untoward Incident to STEIS/SIMS by the commissioning
PCT. STEIS/SIMS has a category called „Admission of under 16s to Acute Mental Health
Ward‟. Details are required of how the child will be moved to appropriate accommodation
within 48 hours. The definitive date is the child‟s date of birth.

     4. Safeguarding Vulnerable Adults Boards
It is expected that all Trust staff promote a safe working environment, which ensures high
quality care is delivered to vulnerable adults. Where staff observe abuse or who have a
concern in relation to a service user they will report those issues as soon as possible to
their line manager (unless they suspect that the manager is involved or implicated when
they should report to a more senior manager within the Trust).

Any allegation of abuse will be reported on to the local authority, as stated within multi-
agency policies. Strategy meetings, which are arranged following any such referral to a
Local Authority, will include representatives from other agencies including Social Services
and the police. This ensures that any investigation of an allegation of abuse is open to
external scrutiny.


Page 66 of 95
An Incident Report Form must be completed stating the actions that have been taken.
Where the outcome of such an investigation indicates that a member of staff has caused
harm through abusing their position of trust, the matter will be referred to the appropriate
governing body. The Trust specialist advisor for vulnerable adults can be consulted for
further advice. (see Appendix T for contact details)

     5. Safeguarding Children Board (See also 2. and 3. above)
It is the responsibility of every individual member of staff employed by the Mental Health
Trust to safeguard children. This responsibility spans all clinical and non clinical
departments and staff at all levels. These responsibilities are clearly outlined in The
Children Act 1989 and Children Act 2004.

It is therefore essential that, when any incident occurs, the impact and consequences on
children are considered, whether or not a child appears to be directly involved. This will
include considering the impact the incident might have on the continued provision of a
safe place to live, or a person to give adequate care beyond any immediately obvious
harm caused e.g. if a service user is hospitalised as a result of an incident, does this have
an impact on any child or children.

In certain circumstances, the death or serious injury of a service user‟s child, grandchild,
or other young relative with whom the service user is in contact, may require further
investigation and will be reported by the PCT as a SUI

The Trust Named Nurse for Child Protection can be consulted for further advice. (See
Appendix T for contact details).

    6. Local Authority Social Services Departments
The relevant Social Services may also have an interest in some incidents where joint care
was provided or where a jointly staffed and managed team or service is involved. The
Trust will liaise with the relevant Social Services Department in relation to any incident
that affects both organizations. If an investigation is needed an agreement will be made
with senior managers about which organization will lead the process.

    7. Health Care Acquired Infection (HCAI) Incidents – report as SUI
Incidents where a HCAI is the primary cause of death should be reported as a SUI. Other
cases which should be reported as SUIs include: clusters of HCAIs, outbreaks which
result in ward closures, recurrent incidences within the same unit, and those which result
in adverse media interest.

    8. Freedom of Information Act 2000
The SHA should be informed of any requests for information regarding Serious Untoward
Incidents submitted under the Freedom of Information Act 2000.

    9. Breaches of confidentiality involving Person Identifiable Data (PID), including
        data loss
Any incident involving the actual or potential loss of personal information that could lead to
identity fraud or have other significant impact on individuals should be considered as
serious and be reported as a SUI in the usual way. The SHA has a role in notifying the DH
of certain data loss incidents, depending on the severity. (See Appendix U)

   10. Care Quality Commission (CQC)
From April 2010 registered providers have a statutory duty to notify CQC in writing about
certain important events that affect people who use their service or the service itself
(Health and Social Care Act 2008).
Page 67 of 95
Notifications must be sent either to the NPSA or CQC (but not both). Notifications must be
submitted within the relevant timescale and include all the information required (see
below). Details of the notification requirements are included in Appendix W. Patient safety
incidents are reported through Datix and the NPSA to the CQC.

    11. National Patient Safety Agency
The Incident Management Support Team provides the National Patient Safety Agency
with information on patient safety incidents on a regular basis. This is done electronically
via the National Reporting and Learning System (NRLS). The findings of incident
investigations affecting patient safety are also reported to the NPSA as appropriate.
Contact the Incident Management Support Team for further information.

   12. Health and Safety Executive including (Reporting of Injuries, Diseases and
       Dangerous Occurrences Regulations (RIDDOR) (1995)
The Health and Safety Executive (HSE) is responsible for regulation of all the risks to
health and safety arising from work activity in Britain; the HSE aim to help people protect
themselves at work and take decisions to make work healthier and safer.

RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995)
to the HSE is a statutory Health and Safety requirements. This should always be done in
conjunction with the Trust Health & Safety Manager, who can also be contacted for further
advice and guidance (see Appendix T). Examples of incidents that might be reportable
under RIDDOR are listed below:
    a.    The death of any person as a result of an accident arising out of or in
          connection with work.
    b.    Any person at work suffering any of certain injuries or conditions as a result of
          an accident arising out of or in connection with work, including:
              o Fracture of the skull, spine or pelvis.
              o Fracture of any bone, except in the hand or foot.
              o Amputation of a hand, foot, finger, thumb or toe.
              o Loss of sight, or serious injury to an eye.
              o Injury as a result of electric shock.
              o Loss of consciousness resulting from lack of oxygen.
              o Acute illness requiring medical treatment, or loss of consciousness
                 resulting from absorption of any substance by inhalation, ingestion or
                 through the skin.
              o Acute illness requiring medical treatment, resulting from exposure to a
                 pathogen (such as a bacterium or virus) or infected material.
              o Any other injury that results in the person injured being admitted
                 immediately into hospital for more than twenty-four hours.
    c.    Any dangerous occurrence, such as an overturned crane or burst pressure
          vessel.
    d.    An employee or other person at work being incapacitated for normal work for
          more than three days as a result of an injury caused by an accident at work.
    e.    The death of an employee if this occurs some time after the reportable injury
          that led to the employee‟s death, but not more than one year afterwards.

Accidents involving non-employees (service user/visitors etc) may require reporting even
where no serious injury has occurred. If a service user/visitor is taken from the scene to
hospital, irrespective of injury, it is still reportable.


Page 68 of 95
The Trust document on Investigations provides guidance on investigating health and
safety accidents, incidents and near misses.

   13. Health Protection Agency
The Trust Infection Control Specialist will, when necessary, inform the Communicable
Diseases Control. See Infection Prevention and Control Policy for further advice and
guidance.

   14. Medicines
Practitioners must report any adverse effects of medicines, in accordance with the UK
Adverse Drug Reaction Reporting Guidelines (set out in the current edition of the British
National Formulary (BNF). The reaction must be clearly documented in the clinical notes
and responsible Consultant informed. Guidance can be sought from the Chief
Pharmacist.

    15. MRHA (Medicines and Healthcare Products Regulatory Agency) and Medical
        Device Incidents
This is a regulatory Authority which has systems in place to oversee the reporting of
adverse reaction to medicines and medical device alerts. Advice and guidance on
reporting can be obtained from the Health and Safety Manager (see Appendix T or
alternatively www.mhra.gov.uk

An adverse incident involving a medical device should be reported on the IRF and also to
the Medicines and Healthcare Products Regulatory Agency (MHRA) - if the incident has
led to or, if it were to occur again, could lead to:
            a. death, life threatening illness or injury
            b. deterioration in health
            c. the need for medical or surgical intervention
            d. unreliable test results leading to inappropriate diagnosis or therapy

The MHRA is informed of other device-related incidents, minor faults or discrepancies that
could, when aggregated with other similar events, indicate quality related problems with a
manufacturer or supplier. The MHRA will be informed of incidents, even if they appear to
be caused by human factors, as they may indicate a weakness in the design of the device
or instructions for use. Serious cases will be reported by the Senior Portfolio Manager,
Risk to the MHRA by fax or on-line reporting, and followed up by a telephone call.

Devices involved in an incident should be quarantined, where possible, until the MHRA
have been consulted.

    16. Fires – external reporting including to NHS Estates
All fires should be reported both internally on an IRF and to external bodies (by the Trust‟s
fire safety adviser) to allow data collection and ensure important lessons are learned.

Fires involving death, serious injury, closure and or significant damage to parts of health
care premises, or its contents, must always be reported via the Nominated Officer (fire
safety adviser) to allow immediate notification to NHS estates. All outbreaks of fire to
which the fire service attend (not false alarms) in NHS premises must be reported to NHS
Estates on a prescribed form.

We also have to report all unwanted fire signals (any actuation of the fire alarm system
when there was no fire) to NHS Estates. Incident details need to be reported via the EFM
system by the Trust Fire Safety Adviser. Unwanted fire signals (false alarms) have to be

Page 69 of 95
monitored and investigated as part of the national concordat between the Government
and the Chief Fire Officers Association. (See Appendix T for contact details)

   17. Department of Health (DoH)
Reporting incidents to the Department of Health is through reporting to other departments
and through other channels such as SUIs through STEIS/SIMS.

   18. NHS Counter Fraud Service
Suspected fraud incidents will be reported on a Trust IRF and also directly to the Local
(Trust) Counter Fraud Service.

   19. NHS Security Management Service
The Trust‟s security management specialist collaborates with the Incident Management
Team on reported incidents of physical assault against members of staff. These incidents
are reported regularly to the national NHS Security Management Service by the Trust‟s
security management specialist. The Trust‟s security management specialist will
investigate further as necessary. (See Appendix T for contact details)

    20. Information Commissioner
Some serious information governance SUIs involving loss of personal data and breaches
of confidentiality – see point 9. above and Appendix U re Department of Health guidance
on incident grading.




Page 70 of 95
                                                                                   Appendix M

 External and internal stakeholders: communicating with and involving
               stakeholders in relation to adverse events
There is a range of internal and external stakeholders who may have an interest in an in
individual incident, incident information and/or the outcome of a Trust investigation. Some
of these are listed below (This list is not exhaustive and not in order of importance). This
process is closely linked to the investigating and analysing incidents, complaints and
claims to learn from experience policy.
Responsibility for reporting and liaison with stakeholders rests with the responsible
manager and will be decided on a case-by-case basis, taking into account the list below.
In reality the relevant Trust specialist adviser will often liaise with external agencies, from
reporting an adverse event to outcome of the Trust investigation.

Internal stakeholders
Staff and Joint Consultative     Knowledge of the incident management and investigation
Committee                         process and how major risks will be managed
                                 Results of risk assessments and control measures
                                 Consultation on new policies, protocols and procedures
Individual staff and teams       Knowledge of the incident management and investigation
                                  process and how major risks will be managed
                                 Communication, information & support following an incident
                                 Feedback following incident investigations
Trust Specialist Advisors        Communication, information and support following an incident
                                 Reporting incidents to external agencies
                                 Liaison with external agencies on investigation processes
Individual Service Users,        Communication, information and support following a patient
Relatives and Carers              safety incident (including feedback on findings of incident
(see Being open)                  investigation and improvements Trust intends to make)
Service User Groups              Knowledge of the incident management process & how major
Advocacy Services                 risks affecting service users will be managed
External stakeholders
Strategic Health Authority       High profile serious incidents and child protection SUIs
Primary Care Trusts              Knowledge of the incident management and investigation
                                  process and how lessons will be learned.
                                 Information regarding Serious Untoward Incidents and
                                  management via the internet based reporting system
                                 Information re adverse events where media or public interest
                                 Copies of key investigation reports & action plans
                                 Sharing relevant lessons learned
Care Quality Commission          Directly - information relating to serious or significant non
See Appendix W                    clinical SUIs
                                 Via the datix and the NPSA NRLS – information relating to
                                  serious patient safety incidents
Care Quality Commission            Deaths and unauthorised absences of people detained or
Statutory Mental Health Act         liable to be detained under the Mental Health Act 1983
monitoring duties
Care Quality Commission –        National NHS Survey undertaken annually by the CQC. Aim of
National Staff Survey             the survey is to gather information and views from staff across
                                  the NHS, including views about incident reporting and learning
                                  from experience. Feedback enables organisations to improve
                                  the working lives of staff and consequently provide better care
                                  for service users and their carers.

Page 71 of 95
Coroner                       Notification of deaths
                              Liaison through the Trust‟s Legal Team
                              May request Trust reports and witnesses
Food Standards Agency         Relevant incident information
General Practitioners         Results of risk assessments and control measures established
                               through the CPA/Section117 aftercare process
                              Information about service user risk factors that will improve the
                               safety of service users, relatives, carers & staff shared in
                               accordance with the Multi Agency Information Sharing Protocol
Health professional bodies    Notification of relevant adverse events and findings
Health Protection Agency      Infection Control Specialist will inform re relevant infections
                                and diseases. See Infection Prevention and Control Policy for
                                further advice and guidance.
Health & Safety Executive     Health and safety incidents under RIDDOR
Home Office and Ministers     Notify in respect of any Serious Untoward Incident relating to
                               Service User‟s held on a Home Office section of the MHA
                              Sharing action plans raised as a result of the internal
                               investigation into the Serious Untoward Incident.
Information Commissioner      SUIs involving breach of confidentiality including loss of
                                 personal data (see Appendix U)
Local Authority including:    Knowledge of the incident management and investigation
                                 process and how lessons will be learned.
Area Child Protection         Reporting and information re relevant adverse events
Committees                    Joint investigation and action planning following adverse
                                 events involving both services eg in joint services
Vulnerable adults             Sharing relevant lessons learned
safeguarding boards           Consultation on new policies and procedures
Medicines and Healthcare      Report all medical devices incidents
Products Regulatory           Report all adverse effects of medicines (UK Adverse Drug
Agency (MRHA)                   Reaction Reporting Guidelines) as set out in British National
Medicine Control Agency         Formulary (BNF). www.yellowcard.gov.uk or MHRA website.
NHS Estates                   Relevant incident information
National Patient Safety       Patient safety incident information uploaded from Trusts risk
Agency (NPSA) & National        database, datix (when, how and why an adverse incident has
Reporting Learning Service      occurred together with the action plans/improvement strategy
(NRLS)
Members of the public and       Public interest and wider societal interests through Trust
media                            Communications Dept
Police                          Reporting & joint working re relevant adverse events eg
                                 where a crime may have been committed
                                Sharing relevant lessons learned and action plans raised as a
                                 result of internal/external investigations
                                Consultation on new policies and procedures
Probation Service               Multi agency information sharing through MAPPA (multi
                                 agency public protection arrangements)
                                Sharing of relevant lessons learned and action plans raised
                                 as a result of internal/external investigations




Page 72 of 95
                                                                                                   Appendix N
                                          Risk Assessment Form (generic)
   This form is intended to inform risk evaluation and decision-making and provide a record of these
   processes. It can be used to risk-assess existing hazards or situations, new or proposed changes
      to systems (which might present a hazard), and some clinical decisions. It is not intended to
        replace specialist risk assessments eg moving and handling – see Health and Safety file.
    Consider carefully who needs to be consulted/ asked to contribute – the outcome will be
                 more robust if the right people have been involved in the process.

Service and                                              Department or
area                                                     Team
Manager                                                  Director, AD or
                                                         AMD
Assessor                                                 Assessment Date

1. Identify the hazard What is being risk-assessed? Why? What could go wrong/cause harm?
    Hazard = potential for harm - could be a process, treatment, activity, environment etc




2. Decide what could go wrong Who could be harmed? How? How often? How badly?




3. Evaluate and assess the risk (record your decision-making process)
3.1 What is currently in place to manage, reduce or limit the risk?




3.2 Use the matrix to assess the current risk Circle/highlight risk grading taking into account:
i) likelihood   ii) impact      iii) what is already in place to limit/manage the risk (identified in 3.)
                                                                 Impact
Likelihood                               (if it happened, how bad would the outcome be?)
                                           minor           moderate             major           catastrophic
(How likely is it and        unlikely     green             green              amber                 red
how often might              possible
someone be
                                          green             yellow             amber                 red
                             probable     yellow            yellow              red                  red
harmed in this
way?)                        likely or    yellow            amber               red                  red
                             certain
3.3 Are there other factors that impact on any risk? eg increase, limit, mitigate, positive
benefits




  Page 73 of 95
4. Are there any further actions/precautions which will or could be put in place to
   manage/reduce/remove any risk? These need to be realistic, sustainable, and
     effective.
        What action                                               Lead                       Timescale
1




2




3




5. Re-assess the risk for final risk grading Circle/highlight the risk grading (taking into account
likelihood, impact and additional safety measures put in place or are planned to limit/manage the risk)
                                                      Impact (if it happened, how bad would it be?)
Likelihood                                    minor           moderate             major         catastrophic
                            unlikely         green             green              amber              red
(How likely and how         possible
often might someone
                                             green             yellow             amber              red
                            probable         yellow            yellow              red               red
be harmed in this way?)
                            likely or        yellow            amber               red               red
                            certain
6. Do you need to consider further specialist risk assessments?                              Yes          No
e.g Moving and Handling, Health and Safety, COSHH etc
7. Record your decision, how it was reached and any date of implementation
It may be reasonable to accept some degree of risk if the benefits outweigh the risk, but you need
to show that:    i) A thorough check was made to identify and address hazards
                    ii) Any precautions, actions or decisions taken are reasonable




8. Review and update your risk assessment Set a date/time for review and updating



    Risks identified as amber or red at stage 7 should be discussed with a senior manager and
    consideration given to including it on the risk register. All completed risk assessment
    forms should be retained locally for reference (in the Health and Safety Risk Assessment
    file/folder) by the department, ward, team or service manager




    Page 74 of 95
                                                                                                                                 Appendix O
                                                                          Incident Ref no.
             Incident Investigation - Action Plan                         General Manager and service


Ref    Team/s         Recommendations              Action Required/Taken                  Lead         Time-      Progress/ comments re
No       or                                                                             (name &        scale           completion
       service                                                                            title)      (month/
                                                                                                       year)
1.

2.

3.

4.

5.


                                                Action plan implementation monitoring
Any resource issues identified

Outcome of risk assessment of impact of
changes to systems or practice (see risk
assessment format)
Action plan                                                Date action plan issued:
developed by:
Approved by:                                               Action plan review date/s:

Signed off as                                              Date signed off as completed
completed by:
NB: Please ensure that all identified action leads have agreed to this lead role and have a copy of the action plan




Page 75 of 95
REPORTING AND REVIEWING SERVICE USER DEATHS -
who have received care in the last 6 months


            EXPECTED                                        UNEXPECTED                                           SUICIDE                              HOMICIDE (of /by                          Appendix P
             DEATH*                                           DEATH                                            (Suspected)                                service user)



    IRF completed, graded,                               IRF completed, graded                            IRF completed, graded                     IRF completed, graded
         manager review                                    (usually amber/red),                        (usually red), manager review             (usually red), manager review
    (Include cause of death)                                 manager review

                                                                                                                                                                                 NOTE: Reporting deaths
                                                              MGT FACT-                                          MGT FACT-                             MGT FACT-                 to Coroner - Trust has
                                                             FIND REPORT                                        FIND REPORT                           FIND REPORT                legal duty to inform
Green           Amber
                                                                                                                                                                                 Coroner of any inpatient
  or              or
                                                                                                                                                                                 death – usually done by
Yellow           Red
                                                                                                                                                                                 most senior medical staff

                                                                           DEATH                                                  External reporting
                                      DEATH                          UNEXPLAINABLE                        May lead to             eg SHA/PCT (SUI)                               NOTE: Other external
                                   EXPLAINABLE                       ie awaiting coroner‟s                                                                                       agencies – some deaths
                                  ie natural /physical                      verdict                                                                                              will need other external
                                   cause confirmed                                                                                                                               reporting & investigation –
                                   Update IRF/Datix                                                                          Incident scoping & agree                            IMST will advise
                                  with cause of death                                                                    investigation Terms of Reference
                                                                     CASE REVIEWED
                                                                     By DIR of N, MEDICAL
                                                                     DIR or deputy

                                                                                                                                                                                           EXTERNAL
                                                                                                                                                                                            ADVICE/
         Manager identifies and                                                                                SYSTEM                                  INTERNAL RCA
          shares any learning
                                                                                                                                                                                         INVESTIGATOR
                                                     Not reportable               SYSTEM                       CHECK               May lead to        INVESTIGATION
             opportunities                              to SHA                                                                                                                            AS REQUIRED
                                                                                  CHECK                        REVIEW
                                                                                  REVIEW

                                                                                                                      Internal quality standard review
                                                   No                  System issues                                                                                                      Homicides
     NO FURTHER ACTION                                                   identified?                                                                                                  Independent review
                                                                                                                                                                                       commissioned by
                                                                                                                 REPORT & ACTION PLAN TO SHA/PCT                                             SHA
                                                                                        Yes
     Key:
     IRF      Incident Report Form                                                                              Sharing lessons learnt
     SUI      Serious Untoward Incident                                                                                                                           Action plan monitoring
     SHA      Strategic Health Authority
     RCA      Root Cause Analysis                                                     Page 89 of 101
     Page 76 of 95
     IMST Incident Management Support Team
     *not patient safety incident
                                                                             Appendix Q

           Incident record keeping and record retention
A. Incident Report Forms (IRFs)
1. Incident Reporting Forms (IRFs) – paper and electronic (datix-web)
An IRF should be fully completed as soon as possible after the incident and passed to
the appropriate line manager within 24 hours. It is essential that:
    All relevant sections are fully completed
    Information provided is accurate and factual, not personal opinion. (If an opinion is
     given it should be made clear that it is an opinion and not given as fact.)
    Paper forms are legible and in black ink.

The line manager is responsible for validating the content of the form and the grading,
for identifying any further actions required and signing-off the IRF to ensure that
incidents are reported appropriately.

2. Transferring Incident Report forms (IRFs)
Each IRF is a confidential document.
     Electronic forms transferred via Datix-web are within a secure system.
     Paper forms: Information Governance procedures should be followed when
      transferring completed paper forms from a ward or team for entry onto Datix.
      Guidance can be provided by the Trust‟s Information Governance lead. Forms
      should be transferred in sealed envelopes (not transit envelopes), addressed in
      full. Alternatively Safehaven fax machines can be used.

3. Storing and filing Incident Report Forms
     Electronic Datix-web IRFs: Datix-web is a secure database where IRFs can be
      securely stored. Access is by password and restricted on a „need to know‟ basis.
      As with other secure systems passwords should not be shared and staff should
      not leave a PC unattended while logged on to the system. It is not necessary to
      retain a paper copy, and staff are advised not to print paper copies of an incident
      - although this facility is available for exceptions.
     Paper incident report forms: If a paper IRFs has been completed it is the
      responsibility of the manager to ensure a copy of the form is retained in
      ward/team/dept for future reference. Any paper IRFs, including copies of
      completed electronic IRFs, need to be stored securely to ensure confidentiality. It
      is recommended that a system for storing any paper IRFs is in place.
     Copies of the IRF should not usually be filed within a service user‟s
      healthcare record. The IRF represents a Trust risk management process rather
      than a clinical process - although at times the 2 processes will overlap. If filed
      within the service user‟s record they become a part of the disclosable healthcare
      record; they may also contain information about other parties.

4. Archiving and retaining Incident Report Forms
       Electronic datix-web IRFs are stored securely on the system. The system is
         an archive - it is not necessary to print and archive paper copies
       Paper IRFs: service managers are responsible for retaining completed paper
         IRFs for their area for a period of 10 years. Incident report forms for the past
         three years should be stored on site for ease of access; the remainder should
         be archived in the Trust‟s offsite storage facility (please contact the Incident
         Management Support Team for guidance on archiving procedures).
Page 77 of 95
B. Other incident information
1. Other incident management information
Some incidents will generate the need for additional incident management records. In
these cases setting up an incident management file (which might be electronic, paper
or both) is recommended. This may include:
    The contemporaneous file note record of the incident management processes
      and actions
    Recording contacts/communication with relatives and carers
    Recording support offered to staff
    Completion of management fact find reports, incident investigation reports and
      action plans.

The incident management file is a confidential record and so should be stored
securely, but as a separate file to the service user‟s healthcare record. It will not
usually be filed in or considered to be part of a service user‟s healthcare record.

2. Securing records after a serious incident including an SUI or Red incident
After a serious incident, has occurred, including a SUI or RED incident, it may be
necessary to remove clinical and other paper records from the service and keep them
secure in order to protect their integrity and prevent any further entries or amendments
being made. The person in charge of the ward or team at the time of the incident or
afterwards will be responsible for doing this.

The General Manager is then responsible for ensuring that all the records relevant to
the incident including healthcare records are gathered together for safe keeping and
are properly secured. The Medical Records Departments across the Trust will be able
to assist with this process, and ensure that any other clinical records the Trust holds
for a service user (eg in another geographical area) are located and secured. See
Appendix T for contact details for Medical Records Departments. The general
manager will be responsible for keeping a log of access to the records, whether that is
for the investigation, Coroner or police. These records may also be required for the
investigation process. Records may include:
      Paper clinical records obtained from medical records. (Medical records will
        ensure that a tracer system is in place to track the location of records.)
      Paper clinical records from teams and services Community Mental Health
        Teams, Assertive Outreach Teams, Crisis Teams, therapy staff, etc.
      Clinical records from electronic systems
      Management records eg rota sheets
To ensure no further entries or amendments can be made to records the general
manager or equivalent should:
Paper records:
   Remove the paper records from use
   If necessary provide a duplicate record
   Following the last entry in the records make an record relating to the serious
    incident, which must be dated, timed and appropriately signed by the General
    Manager or deputy.
   Rule a line under this entry to prevent any further recording in the record.
   Any blank pages within the record should also be ruled through.

Page 78 of 95
Electronic records:
    A record of the incident should be made
    The electronic system will record other entries or amendments made post
      incident
    In the event of a service user death:
       o Clinically discharge the person on RiO by using „patient death‟ as the
          discharge reason.
       o The manager should inform the RiO team of the death as soon as possible.
          They will then adjust the electronic record accordingly centrally after
          confirming the death with the GP.
3. Copying paper records after a serious incident and/or patient death
Often following a serious incident original paper healthcare records are required by
another agency, for example:
 a. Service user is transferred to another unit, team or hospital for further/ongoing
    treatment or care
 b. The original records are required by another agency and the service user‟s care
    continues in our trust. A duplicate copy in a temporary file may be required to
    record clinical information. (These will clearly state that it is a duplicate record and
    describe the incident.)
 c. Service user death - the Coroner or police to ask for the original records for their
    investigations. This can be without any notice.
 d. Where a crime is suspected or alleged the records may be required by the police

With this in mind, it is important that a copy of the full set of any paper records is made
as soon as possible after a serious incident where it is possible the notes will be
required by another agency. This is so that the trust has access to information for any
ongoing care and treatment, and/or for investigation and report writing purposes

Ideally copies of healthcare records should be carried out by the medical records
department. However, requests for records can be made out-of-hours, or without any
notice, and it may be expedient for the local team to copy any paper records. The
responsible manager should use their discretion in making this decision.
4. Serious untoward incident management file
Information about managing the SUI will not be recorded in the healthcare records
except in relation to the provision of healthcare. The General Manager, or equivalent
manager in a non-clinical area, will need to ensure that accurate record keeping on the
management of the SUI is undertaken to demonstrate the actions taken.

As a minimum, a file note should be commenced as soon as a SUI is reported to the
General Manager to record all actions taken, and all entries should include date, time
and name of the person adding the entry. Entries should record:
    decisions making process (including who by)
    who has been contacted
    contact with service users, carers and relatives
    correspondence
    outcome of discussions
    actions to be taken

The incident management file should also contain a record of access to any secured
records , by whom, when etc.

Page 79 of 95
5. Post investigation – where to keep the records
All investigation reports and action plans must be approved by a responsible director
prior to them being sent to an external organisation such as the PCT, SHA or Coroner.
This will usually apply to an SUI and the Incident Management Support Team (IMST)
will liaise with the relevant Director. SUI investigation evidence, including any paper
healthcare records, should be retained locally until this approval is given. Investigators
and the service manager (general manager) will be notified of this by IMST.
Healthcare records
Following the completion of an incident investigation, report writing and approval
process, all original paper healthcare records/case notes should be returned to the
appropriate medical records department for safe storage. File tracers will be updated
by medical records department to ensure the records can be located in the future.
(Ideally Medical Records will retain these records on site rather than archiving them to
external storage).

C. Incident related record retention
Record retention requirements for incident-related documentation is complex. The
requirements are set by the Department of Health (Records Management - NHS Code
of Practice). It is recommended that the Trust‟s Information Governance policies and
procedures are also consulted. The key Trust policies are:
   Non-clinical records management policy
   Clinical Records Management policy and guidance

Summary of the Department of Health records retention schedule including incident
related documents

 Type/subtype of record                          Minimum retention period        Final action

 Accident forms (see also litigation dossiers)   10 years

 Accident register (Reporting of Injuries,       10 years
 Diseases and Dangerous Occurrences
 register) – see also Incident forms

 Complaints (See also litigation dossiers)       8 yrs from completion. Files
 Correspondence, investigation and               closed annually and kept for
 outcomes. Returns made to DH                    6 yrs following closure         Destroy under
                                                                                 confidential
 Data Input Forms (where the data/information    2 years                         conditions
 has been input to a computer system)

 Health and safety documentation                 3 years

 Incident forms                                  10 years

 Litigation dossiers (complaints including       10 yrs - where a legal action
 accident/ incident reports). Records/           has commenced, keep as
 documents relating to any form of litigation    advised by legal
                                                 representatives

 Serious incident files                          30 years



Page 80 of 95
                                                                              Appendix R
Control Rooms and Hotline Arrangements
This guidance should be read in conjunction with the Trust’s Major Incident and
Business Continuity Plan and Media Policy.

If there is a major incident impacting on the Trust, responsibility for the management of
that incident may be placed with another organisation. Up-to-date contact details for all
other organisations are held by the Chief Executive‟s Office. The Trust would fully co-
operate with that organisation to manage the incident.

There may be circumstances where it would be important for the Trust to set up
specific communication arrangements. The decision for when a response of this nature
is required will be made by members of the Executive Management Team. Part of
these arrangements may include the setting up of a control room and/or a helpline.

The Directors with responsibility for operations and for public affairs would be
responsible for co-ordinating actions to set up a Control Room or a Helpline. The
Director with responsibility for Facilities management will also have a key role in
ensuring practical support arrangements are made, eg room, telephones, change of
use of a room, equipment availability etc. Procedures for dealing with these situations
are outlined below, but should be read in conjunction with the Trust Major Incident and
Business Continuity Plan and the Media Policy.

Setting up a Control Room
If an incident occurs that is likely to impact on the Trust‟s ability to provide normal
services, a control room should be established, where relevant staff come together to
form an incident co-ordination team. The incident co-ordination team, lead by the
relevant Director, should include:
                   The relevant lead service manager (general manager)
                   An additional service manager
                   Relevant specialist advisors (eg communications, risk management,
                    infection control, emergency planning)
                   Administrative support staff
                   Other professionals as appropriate

Authorisation to release appropriate staff to form part of the team will be made through
the Executive Management Team, dependent upon the incident.

The incident co-ordination team‟s role is to ensure that the management of the incident
does not detrimentally affect continuity of service delivery. Responsibility should be
allocated for management of the incident and for maintaining services. The team will
also be responsible for liaison with any other agencies involved (eg police or fire
brigade) to ensure they are able to fulfil their responsibilities within minimum disruption
to patient services. The team would also be responsible for liaising with the
Communication Department (Appendix T), as appropriate, to communicate information
both internally and externally.

Staff in the team will be required to ensure that they maintain contemporaneous
documentation, including a log of received calls, advice given, decisions and actions
taken.

Consideration should be given to the setting up of this room as close as possible to the
scene of the incident. The room should be equipped with the following equipment as a
minimum:
Page 81 of 95
                  Telephone
                  Computer with email access
                  Relevant documentation
                  Secure storage facilities
                  A white board or flipchart

Outside normal working hours, the team would include as a minimum, the on-call
Manager and on-call Director (Appendix T)

Setting up a Helpline Centre
Some incidents could prompt multiple enquiries from patients, members of staff or the
general public. In these cases a Helpline centre would be established (this could be as
well as a control room). The Helpline Centre would provide a communications centre
where appropriately briefed staff could respond to enquiries. As with establishing a
control room, a suitable room will be identified with support from Facilities Department.

The Helpline Centre should include, as a minimum:
                 A suitable number of telephones
                 Access to a computer and email
                 Relevant information or documentation
                 Secure storage facilities
                 A white board or flipchart

Facilities Department will support these requirements.

Staff allocated to the Helpline Centre could include qualified clinicians who are able to
respond directly to clinical issues (or other staff if it is a non-clinical issue),
administrative staff to receive and file incoming calls, consideration should be given to
the use of qualified counsellors, if appropriate. If the helpline is required for an
extended period, staff will be allocated on a rota basis.

Authorisation to release appropriate staff to form part of the team will be made through
Executive Management Team dependent upon the incident.

All staff receiving calls will be:
     Fully briefed by the Communications Team on what information to give, how to
        record calls and what to do in the event of media inquiries.
     Required to ensure that they maintain contemporaneous documentation,
        including a log of received calls, advice given, and actions taken.

An email address should be available on the internal computer network for sending
information to the helpline staff. IT Department will notify relevant staff of the email
address (this will differ dependant upon the location of the helpline).

Other methods of communicating and dealing with multiple enquiries eg postal
arrangements will be led by the Director with responsibility for Public Affairs through
the Communication Team (see Appendix T).




Page 82 of 95
                                                                              Appendix S

Guidelines for staff on producing written statements for internal
reviews and investigation following an adverse incident
These are general guidelines. Specific situations may require more detail. Liaise with
the legal services team for advice. In difficult or sensitive cases, legal advice will be
considered.
  o Any statement (unless it is actually prepared during the course of pending or
      ongoing litigation), may at some time be scrutinised not only by managers and
      lawyers representing the interests of the Trust, but also by others.
  o A statement in one context may well also be used in another. If a witness gives
      evidence that contradicts a statement previously made by that witness the
      previous statement can be put to the witness and he/she will have to explain the
      difference. This can affect the credibility of the witness. For all these reasons it
      is important that any statement is accurate, carefully considered and that the
      maker retains a copy for future reference.
  o Statements given might in subsequent years be the only evidence the Trust will
      have about what happened in a particular case – give full accurate information.
  o If medical records and other documents are relevant it may be helpful to refer to
      these in the statement. If any notes are being referred to, then it is usually helpful
      to have a transcript of these notes incorporated into the statement.
  o If circumstances allow it is a good idea to leave a statement at least overnight
      and review it again before signing. It may be helpful to have the draft read by
      someone else to check that it makes sense to an uninvolved reader (but not by
      someone else involved in the incident).
  o Keep a copy of any statement you make. If this is not possible (eg the police do
      not like to allow copies while an investigation is being undertaken) seek
      agreement that a copy will be provided when the rest of the evidence has been
      gathered.
                                          Taken from Hempsons Solicitors Advice (2006)

Do
     o   Use the Trust template for your statement
     o   Make sure it is legible and if possible typed - it is an important document
     o   Only include factual information - not speculation, assumptions or opinions
     o   Be completely honest
     o   If you cannot remember something, say so.
     o   Use first person singular - „I did ‟ „I said‟
     o   Set out full dates eg 27.06.06 - not 27.06 or Monday.
     o   Remember incident reports and statements are disclosable documents
     o   If possible - sleep on it & ask someone not involved in the incident to read it
         and comment
     o   Keep a copy for yourself.

Don’t
    o    Prepare a statement without access to records
    o    Prepare your account entirely from memory
    o    Just repeat what is in the records
    o    Include opinions or speculations - just facts
    o    Comment on or be critical of care given by colleagues
    o    Submit an untidy or illegible account


Page 83 of 95
                                                              Appendix S (continued)

                     Trust witness statement template
                                       (2 pages)

                                Witness statement
 1. Full name and current work contact details (address and telephone) of
    statement maker:


 2. Current post held – title, role, team, service:


 3. Post held at time of incident (if different) - title, role, team, service:


 4. Details of professional and other relevant qualifications and a brief
    curriculum vitae (eg two years hands on experience might be very relevant).


 5. If statement maker under supervision at the time of the incident state this
    and by whom:


 6. Incident details

      Date of Incident:
      Time of incident:
      Place where event took place (eg Ward/Dept):

If a service user/s and/or carer/s were involved:

 7. Service user details:
     Name:
     Date of Birth:
     Address:
     NHS Number:

 8. Carer details:

 9. Details of statement makers involvement in the service users care leading up to
    the incident and at the time of the incident

 10. At the time of the incident was the statement maker the primary nurse or care co-
     ordinator for the service user? If so please state which:




Page 84 of 95
Statement:

    o   Set out the story. Give as much information about the incident and/or related
        factual matters as possible.
    o   It is important that statements relating to involvement in the treatment of a
        patient are made with reference to the medication records. If the records are
        not available when the statement is being made state this here.
    o   How good is your recollection of the incident? If you do not remember certain
        details, then this should be made clear in the statement.
    o   Say what your involvement in the incident was (other witnesses can explain
        their own involvement). The golden rule is “what you did, what you heard, and
        what you saw”.
    o   List any other known witnesses and the parts other people played here (with
        names and job titles):
    o   If a decision was made jointly this should be set out in the statement eg”…..
        and I agreed that I should do this ……”. It is not helpful to say “……..it was
        agreed we should……….”. This neither explains who decided nor who was
        going to do the “doing”.

    o   Refer to any relevant protocols or standard procedures
    o   Avoid using hindsight to retrospectively evaluate what happened at the time.
    o   If shorthand notes or abbreviations are being referred to, then those should be
        explained fully and a translation provided.
    o   Once a statement has been completed then it should always considered
        carefully and then signed by the witness and dated again with the full date.


I hereby acknowledge that to the best of my recollection this is an accurate
statement of events related to the incident identified above:


Date:

Sign and date each page




Page 85 of 95
                                                                                 Appendix T
                         Contacts for advice and support

                       Advice                                        Contact
Incident Management Support Team                         01422 281334     risk@swyt.nhs.uk
Customer services team (complaints, concerns             01924 327084 complaints@swyt.nhs.uk
comments, compliments)
Communications Team                                      01924 327055
Human Resources                                          01924 327003
IT Project Manager                                       07900680577
Legal Services Team (including claims)                   01924 327080 / 01924 327408
Trust Specialist Advisers
Chief pharmacist                                         01422 281352
Counter fraud specialist                                 01924 816098
Fire safety adviser                                      01924 328681
Health and safety adviser                                01924 327475
Infection prevention and control adviser                 01924 327063
Information governance portfolio manager
                                                         01422 281345
 (also in first instance for Caldicott Guardian)
Management of violence & aggression network              01924 327064
Medical Records - North Kirklees                         01924 816902
Medical Records - South Kirklees                         01484 343526/7
Medical Records - Calderdale                             01422 222801
Medical Records - Wakefield                              01924 327232
Mental Health Act - Yvonne French, Julie Carr or         01924 327080
Margaret Price                                           or 01924 327437
Moving and handling adviser                              01924 328617
Safeguarding children - named nurse                      01924 327560
Security management services adviser                     01924 327103
Security specialist                                      01924 327323
Vulnerable adults adviser                                01924 328630
Professional advisers
Assistant director, psychological therapies              01924 327560
Director of nursing, compliance and innovation
                                                         01924 327577
(Caldicott Guardian)
Assistant directors of nursing                           01422 281356
Medical director                                         01924 327491
Directors and Senior Managers
Director accountabilities are described in the Risk Management Strategy
General and service managers, modern matrons
Out-of-hours: on call manager can be contacted through relevant switchboard
Fieldhead Hospital (to 17.30 pm then Pinderfields)   01924 327000
Pinderfields General Hospital                        0844 8118110 or 01924 212039
Huddersfield Royal Infirmary                         01484 342000
Calderdale Royal Hospital                            01422 357171
Strategic Health Authority - Integrated Governance   0113 295 2089
Incident Report Form books (paper)                   facilitieshotline@swyt.nhs.uk




   Page 86 of 95
                                                                                              Appendix U

     Information governance (IG) incidents - incidents relating to
  confidentiality breach, data loss incidents, records and IT systems
Identifying and reporting IG incidents
Information governance (IG) incidents should be reported and recorded in the same
way as any other incident. IG incidents are wide ranging, may relate to any personal or
other information (including that relating to staff, service users, etc) and may include:
     Missing/lost/destroyed person identifiable records or information (electronic or
       paper).
     Unauthorised access to records (by deception, misuse of staff access, break in)
     Data quality issues such as wrongly addressed or poorly recorded clinical
       information
     Systems issues including corruption of data and viruses
     Loss or theft of IT equipment containing person identifiable information.
     E-mails sent containing person identifiable information
     Inadequate disposal of confidential waste
     Inappropriate sharing of person identifiable information
     Loss or damage to corporate records.

The Portfolio Manager: Information Governance & Health Records (IG&HRecs)
(who also holds the role of Data protection Officer for the Trust) can be contacted for
advice. The Director of Nursing, Compliance and Innovation is the Trust‟s Caldicott
Guardian and Senior Information Risk Officer (SIRO), and can be contacted for advice
in more serious cases or if the Portfolio Manager:(IG&HRecs) is unavailable.

Severity grading of IG incidents
Although the Trust‟s risk grading matrix applies to IG incidents, the Department of
Health (DofH) has provided additional guidance on reporting and defining incident
severity in relation to confidentiality breaches and loss of personal healthcare
data (see Table 1 below). IG incidents which fall into categories 1 to 5 on the DofH
table will be graded as red and managed as a SUI by the Trust.
Table 1
      0                   1                   2                 3                 4                 5
   Other                                 Red (Serious untoward incident)
   grade
No significant    Damage to an         Damage to a        Damage to         Damage to an      Damage to
reflection on     individuals          teams              services          organisations     NHS
any individual    reputation           reputation         reputation        reputation        reputation
or body           Possible media       Some local         Low key local     Local media       National
Media interest    interest eg          media interest     media             coverage          media
very unlikely     celebrity involved   that may not go    coverage                            coverage
Minor breach      Potentially          public             Serious           Serious breach    Serious
of                serious breach.      Serious            breach of         with either       breach with
confidentiality   Less than 5          potential breach   confidentiality   particular        potential for
Only a single     people affected      and risk           eg up to 100      sensitivity (eg   ID theft or
individual        or risk assessed     assessed high      people            sexual health)    over 1000
affected          as low eg files      eg encrypted       affected          or up to 1000     people
                  were encrypted       clinical records                     people affected   affected
                                       lost. Up to 20
                                       people affected


Page 87 of 95
Serious and potentially serious IG incidents
Any serious IG incident (potentially graded red - categories 1 to 5 in the table below)
will be notified to the Portfolio Manager (IG&HRecs) and/or the Incident Management
Support Team (IMST), by the responsible manager as soon as possible after the
incident has occurred.

A management fact find report should then be completed within 24/48 hours, in
accordance with the Incident Management and Reporting Policy, and copied to the
responsible manager, the IMST and the Portfolio Manager (IG&HRecs). (This can be
done via datixweb). The Portfolio Manager (IG&HRecs) will then review and confirm
the severity grading of the incident in discussion with the responsible manager and,
where appropriate, with the Trust Caldicott Guardian or Senior Information Risk Owner
(SIRO).

The attached DH checklist (Appendix W) must be completed as fully as possible by the
Portfolio Manager (IG&HRecs), and forwarded to the SHA where appropriate. When
complete it will also be stored on Datix against the incident.

Reporting IG SUIs
All IG incidents which are confirmed as an SUI (graded red - level 1 to 5 as defined in
DofH guidance) will be reported as follows:

Internally within the Trust
                                         Timescale                   Reported by
Trust Caldicott Guardian - if service    As soon as possible         Portfolio Manager:
user information is involved             when a potential incident   (IG&HRecs),
Trust SIRO                               is identified or reported
Management fact Find report              24 to 48 hrs                Service manager
DOH checklist initiated                  48 hrs                      Portfolio Manager:
                                                                     (IG&HRecs)

Externally to the Trust
                                        Timescale                   Reported by
Y&H SHA via SUI reporting               Within 24 hours of incident
system (STEIS/SIMS)                     being reported and          IMST
Commissioning PCT                       grading confirmed

Information Commissioner                Within 24 hours of incident
(level 3 – 5)                           being reported and          Data Protection
                                        grading confirmed           Officer (Portfolio
Completed DOH checklist sent to         When information            Manager:IG&HRecs
SHA (levels 3 -5)                       available


Reviewing and analysing IG incidents
All amber and red IG incidents will be individually investigated in accordance with Trust
Policy (Investigating and analysing incidents, complaints and claims to learn
from experience).

   1. The Portfolio Manager (IG&HRecs) will run regular reports on Datix to review
      incidents and identify whether any require further investigation, and/or need the
      grading to be reviewed.


Page 88 of 95
   2. The IG TAG risk sub-group will review new IG incidents; the I on a monthly
       basis; The Portfolio Manager (IG&HRecs will highlight incidents which need
       further clarification.
   3. Where further clarification is required additional information will be requested
       from the team manager. Where appropriate the Datix record will be updated.
   4. Where a lower graded incident appears that it should be reviewed and
       upgraded, or a lower grade incident occurs which may be part of a more serious
       pattern of incidents which could be a SUI, the Portfolio Manager (IG&HRecs)
       will ask the appropriate service lead from the IG TAG to review as appropriate,
       identify any learning points and feed back to the risk sub-group. (Where the
       incident is not related to an clinical service an appropriate lead will be identified
       to review the incident.) The Portfolio Manager (IG&HRecs) will provide advice
       as necessary.
   5. Any incidents which are reviewed in this way will have the DH checklist
       (Appendix V) completed by the identified review lead and forwarded to the
       Portfolio Manager (IG&HRecs) within 5 working days.
   6. The Portfolio Manager (IG&HRecs) will provide a verbal summary of the type of
       incidents, trends and learning points from incidents to the IG TAG.
   7. Learning points will be included where appropriate in the lessons learned
       newsletter
   8. An annual report will be presented to the IG TAG providing an overview of the
       numbers, type and severity of incidents.
   9. All information governance SUIs graded 3, 4 and 5 will be individually reported
       in the Trust‟s annual report (using Table 2 below).
   10. Information governance SUIs graded 1 and 2 will be aggregated, categorised
       and included in the Trust‟s annual report (using Table 3 below).
Table 2
    Summary of SUIs involving personal data as reported to the Information
                      Commissioner’s office in (year)
 Date of incident     Nature of      Nature of data    Number of people        Notification
    (month)           incident         involved        potentially affected      steps

Further action on information risk

Table 3
  Summary of personal data related incidents (severity grading 1 or 2) in (year)
Category Nature of incident                                                 Total
    I       Loss of inadequately protected equipment, devices or paper
            documents from secured NHS premises
    II      Loss of inadequately protected electronic equipment devices or paper
            documents from outside secured NHS premises
    III     Insecure disposal of inadequately protected electronic equipment,
            devices or paper documents
   IV       Unauthorised disclosure
   V        Other




Page 89 of 95
                                                                                      Appendix V

       Department of Health checklist for Information Governance (IG) incidents
  For completion where an IG incident is identified as level 1 – 5 (SUI - red), or where an
  incident is investigated with the view to upgrading the incident. The checklist will be stored on
  in the Datix incident record and sent to the SHA for level 3 – 5 incidents.

Unique SUI or other incident reference number :
Initial assessment of level of incident (1-5):
SHA Responsible: Yorkshire and the Humber
Local Organisation(s) involved: South West Yorkshire Partnership NHS FT
     Required Information                       Check
01 Date, time and location of the incident
02 Confirmation that DH guidelines for incident
    management are being followed and that
    disciplinary action will be invoked if appropriate
03 Description of what happened: Theft, accidental
    loss, inappropriate disclosure, procedural failure
    etc.
04 The number of patients/ staff (individual data
    subjects) data involved and/or the number of
    records
05 The type of record or data involved and sensitivity
06 The media (paper, electronic, tape) of the records
07 If electronic media, whether encrypted or not
08 Whether the SUI is in the public domain and
    whether the media (press etc.) are involved or
    there is a potential for media interest
09 Whether the reputation of an individual, team, an
    organisation or the NHS as a whole is at risk and
    whether there are legal implications
10 Whether the Information Commissioner has been
    or will be notified and if not why not
11 Whether the data subjects have been or will be
    notified and if not why not
12 Whether the police have been involved
13 Immediate action taken, including whether any
    staff have been suspended pending the results of
    the investigation
14 Whether there are any consequent risks of the
    incident (e.g. patient safety, continuity of treatment
    etc.) and how these will be managed
15 What steps have been or will be taken to recover
    records/data (if applicable)
16 What lessons have been learned from the incident
    and how will recurrence be prevented
17 Whether, and to what degree, any member of staff
    has been disciplined – if not appropriate why?
18 Closure of SUI – only when all aspects, including
    any disciplinary action taken against staff, are
    settled.
Notes:




  Page 90 of 95
                                                                           Appendix W

                   CQC A new system of registration
     Notifications required by the Health and Social Care Act 2008
                      Guidance for NHS providers
From April 2010 registered providers have a statutory duty to notify CQC in writing
about certain important events that affect people who use their service or the service
itself. The above guidance describes:
     The incidents and events that NHS providers must notify us about.
     How NHS providers should submit a notification.
     How to find out more about notifications requirements.

This summary covers the notifications relevant to incidents reporting.

A. Notifications – overview

Notifications must be sent either to the NPSA or CQC (but not both)
The law requires that notifications about relevant events are sent either to the NPSA or
CQC – but not both. Reporting relevant incidents to the NPSA meets the legal
requirement. Trust patient safety incidents are reported to the NPSA via an IRF
(Incident Report Form) on Datix.

Some types of notification must be submitted directly to CQC, but most via the NPSA,
which already has systems in place to receive and process reports about patient safety
incidents in NHS trusts. The NPSA will receive and process these reports, and pass on
relevant information to CQC. This avoids unnecessary duplication.

Timescales
Notifications must be submitted within the relevant timescale and include all the
information required (see below).

What to notify
    Changes to the organisation‟s statement of purpose (not as an incident)
    Certain important changes to the service (not as an incident)
    Certain deaths of people who use the service
    Deaths and unauthorised absences of people who use the service who
      are detained or liable to be detained under the Mental Health Act 1983
    Serious incidents affecting people who use the service
         o Injuries
         o Deprivation of liberty applications
         o Any abuse or allegation of abuse
         o Events that stop or may stop the registered person from running
             the service safely and properly

How to notify
The CQC has developed forms for the notifications that are made directly, which are
available from the CQC website to fill in electronically.

Unauthorised absences and deaths of people liable to be detained under the Mental
Health Act are dealt with under a different process to the other directly submitted
notifications. This is because they are part of CQC Mental Health Act monitoring
Page 91 of 95
functions. Notification forms for these and information about how to submit them are on
the CQC website. The Trust‟s Mental Health Act office will advise on this process.

Confidential information
 It is against the Data Protection Act 1998 to submit a notification that included
  confidential personal information such as a person‟s name, or any other information
  that could identify an individual.
 Notifications should use a unique identifier or code, rather than a name, when giving
  information about an individual in a notification.
 The unique identifier or code on the form should be decided by the Trust and be the
  SUI, incident or other reference number used by the Trust.
 The Trust should keep a record of the codes given in each notification and who they
  refer to in case the CQC need to know more about the event.

Subsequent actions
Some notifications may be about routine events that require no further action. But
where a reported incident or pattern of reports is significant and affects the safety of
people using the service, CQC will assess what action the Trust has taken and
respond accordingly.

What if an NHS provider re-submits the same incident with more information
later on? The Trust should use the same reference number when we re-submit the
incident, and explain that it is a re-submission with more information in an appropriate
free-text box; the CQC will be able to recognise the report as follow on information.

B. What to notify - details of incidents

 1. Regulation 16: Death of a service user
 Timescale: These notifications must be submitted without delay.

Notify relevant deaths to the NPSA using Datix. This will be uploaded to the NPSA
NRLS by the IMST. These reports must meet the NPSA‟s standards for the relevant
mandatory fields.

 2. Regulation 17: Deaths and unauthorised absences of people detained
    or liable to be detained under the Mental Health Act 1983
 Timescale: The notifications must be submitted to CQC without delay.

These notifications are dealt with under a separate process from that used for most
notifications. This is because of their use in the CQC statutory Mental Health Act
monitoring duties. You can get information about this and download the forms from the
CQC website. The Trust‟s Mental Health Act manager will advise on this process.

Do deaths of people detained under the Mental Health Act have to be notified to
both the NPSA AND CQC under both reporting processes? NHS providers
notifying the death of a person detained under the Mental Health Act 1983 do not need
to send a separate notification to the NPSA (regulation 16). However the Trust
chooses to also report these deaths as an incident on Datix, and send to the NPSA as
well as CQC. The Trust uses the unique Incident ID number on Datix for both reports
(in accordance with CQC requirements) to avoid the NPSA/CQC duplicating death
statistics.
Page 92 of 95
 3. Regulation 18: Notification of „other incidents‟
The law says that providers must notify the CQC without delay about a variety of „other
incidents‟ that take place while an activity is being delivered or as a consequence of an
activity being delivered.
        i) Injuries
        ii) Deprivation of liberty applications
        iii) Any abuse or allegation of abuse
        iv) Events that stop or may stop the registered person from running the service
             safely and properly

Timescale: all „other incidents‟ should be notified without delay

      i) Injuries – the Trust must notify relevant injuries via the NPSA by completing
         a Datix IRF. The report must meet the NPSA‟s standards for the relevant
         mandatory fields.

      ii) Deprivation of liberty applications and outcomes - There is a standard
          CQC form for notifying applications to deprive a person of their liberty under
          the Mental Capacity Act 2005. This will not usually be reported as a Trust
          incident or reported to the NPSA NRLS.

      iii) Any abuse or allegation of abuse – The Trust must make these
      notifications to the NPSA – by completion of an IRF on Datix. This should
      include information about whether you have informed the relevant safeguarding
      authority about the abuse or alleged abuse in the free text „description of what
      happened‟ field of the Trust IRF (Datix), so that the CQC will confirm that this
      has been done

      It is important that you tell relevant local safeguarding authorities about abuse
      and allegations of abuse in relation to Trust services appropriately, as described
      in the CQC guidance about compliance.

      iv) Events that stop or may stop the registered person from running the
      service safely and properly - The Trust must notify relevant infrastructure
      problems to the NPSA via an IRF on Datix. These reports must meet the
      NPSA‟s standards for the relevant mandatory fields.

Notifications of outbreaks and individual cases of infection
These notifications are not made to CQC, who are currently developing information-
sharing agreements with relevant organisations so that they have the information to
assess compliance with infection control requirements.




Page 93 of 95
                                                                                 Appendix X
Definitions
There are a range of different terms and definitions related to risk management,
incidents and adverse events, and patient safety. Key definitions of the terms used
within the Trust and in the context of this and related documents are listed below.

Accident         An unplanned and unwanted event that results in a loss of some kind.
                 An accident does not include near misses..
                 An adverse event could be an incident complaint or claim that requires
Adverse event    investigation by the Trust to identify causal factors. An adverse event
                 may not initially have been recognised and reported as an incident
                 (and so may need reporting retrospectively).
Adverse          Also referred to as an incident or untoward incident. An unintended
Incident         and/or unexpected event or a circumstance that actually lead to, or
                 could have led to, harm, loss or damage to a service user, staff
                 member, visitor/contractor or property. Harm may be physical or
                 psychological.
Causal Factors   A causal factor is something that led directly to an incident.
Datix            The risk management database used by the Trust to record all risk
                 management activity, including incidents, complaints, claims,
                 Coroners inquests and PALS queries. Datix allows us to record and
                 search data eg by severity and category.
                 Patient safety incidents are uploaded to the NRLS on a weekly basis.
Datixweb         Web based version of datix used by the Trust which allows staff to
                 report incidents electronically, and managers to review, approve and
                 manage incident data electronically.
Management       Following initial reporting this is a further information gathering and
Fact Finding     „risk scan‟ that will help determine what happened, any obvious gaps
                 or failures in the systems (where immediate risk reduction measures
                 may be needed) and identify the requirements of further investigation.
Hazard           A danger – something with the potential to cause harm
Incident         An unintended and/or unexpected event or a circumstance that lead
                 to, or could have led to, harm, loss or damage to a service user, a
                 member of staff, a visitor/contractor or to property. The harm may
                 be physical or psychological. It is important to recognise and report all
                 incidents, both clinical and non-clinical.
                 The Trust uses the word incident because this is the term that staff
                 recognise and use most frequently - although untoward Incident or
                 adverse event may be technically more accurate
IMST             Abbreviation for Incident Management Support Team
Investigation    A thorough, detailed, systematic inquiry, search or examination to
                 discover facts. Usually results in recommendations, actions and
                 sharing lessons learned as a result of the incident.
Likelihood       The possibility or probability that an incident will occur or reoccur
NPSA             The National Patient Safety Agency (NPSA) – an NHS body which
                 supports the NHS to learn from patient safety incidents and develop
                 solutions to prevent harm in the future. The NPSA:
                  Collects and analyses patient safety incident data via the NRLS
                  Issues information about identifies risks and solutions
NRLS             National Reporting and Learning System (NRLS) - a data base
                 operated by the NPSA. All NHS Trusts provide information about
                 individual patient safety incidents, to enable the NPSA to analyse
                 national incident data and support the NHS to improve patient safety.
Near-miss        An incident where an event or an omission does not develop further to
                 cause actual harm - but did have the realistic potential to do so. These
Page 94 of 95
or               should be reported as incidents. Near-misses are free lessons and
                 are as important in terms of the way we learn lessons as those events
Close-Call       where actual harm, loss or damage has occurred.
                 A „near miss’ incident could be any severity grade.
Patient safety   The process by which an organisation makes patient care safer. This
                 involves identifying, analysing and managing patient-related risks to
                 improve and make services safer. Reporting, analysing and learning
                 from incidents is an important part of this process.
Patient safety   An incident related to patient care or treatment, which could have or
Incident         did lead to harm for one or more patients receiving care from the
                 Trust. National Patient Safety Agency (NPSA) definition. Sometimes
                 called an adverse healthcare event, a clinical error or incident.
                 How likely it is that the harm from one or more hazards/dangers will
Risk             happen and the consequences or impact that it would have.
                 The chance of something happening and the impact it would have.
Risk             A systematic way of:
Assessment          1. Identifying hazards and risks
                    2. Deciding what harm could result, to who or what and how
Risk                3. Reviewing if these hazards/risks are adequately managed.
management          4. Taking action to control or limit the hazards or risks
and reduction       5. Reviewing the effectiveness of the assessment and action plan
                    6. Recording this process
                 Grading the severity of an incident to enable us to make informed
Risk Grading     decisions about subsequent actions and to analyse incident patterns
and the          and trends. The Trust uses a Risk Grading Matrix to grade incident
Risk Grading     severity The grade of severity is based on the likelihood of something
Matrix           happening and the impact it would have if it did happen.
                 Systematically applying policies, procedures and practice (in the
Risk             context of the Trust‟s purpose and objectives) to:
Management       1. Risk assess - based on identifying and evaluating hazards
                 2. Implement measures to control or manage the risk
                 3. Regularly monitor and review the risk
                 This process can be recorded and monitored using a risk register (see
                 Trust‟s Risk Management Strategy)
Risk Reduction   Reducing the level of risk of recurrence by implementing identified
                 actions eg as a result of lessons learned from an incident.
                 A risk management tool used by organisations to record, prioritise and
Risk Register    monitor identified risks. See Risk Management Strategy.
Root Cause       A systematic retrospective review of an incident undertaken to identify
Analysis         what, how, and why it happened. The analysis is then used to identify
(RCA)            areas for change, recommendations and sustainable solutions, to help
                 minimise the re-occurrence of the incident type in the future.
                 A commitment to make the organisation as safe as possible for
Safety Culture   service users and staff by following policies related to risk and safety
                 and openly reporting incidents and safety concerns.
                 A SUI is a very serious incident eg where a patient, member of staff,
Serious          or member of the public has suffered serious injury, major permanent
Untoward         harm, or unexpected death in some way connected to the services
Incident         provided by the Trust. These incidents are managed with care and
                 consideration, both at the time of the incident and afterwards. Any
(SUI)            incident confirmed as being graded Red on the Trust‟s Risk Grading
                 Matrix would be classed as a Serious Untoward Incident (SUI). It also
                 means that the incident is reported externally to the PCT and SHA, via
                 the DOH data base STEIS (to be replaced by SIMS in 2010), which
                 generates a unique SUI number. A list of examples of what could
                 constitute a Serious Untoward Incident is attached at Appendix I.


Page 95 of 95

								
To top