Policy and procedure for the reporting and management of Serious Untoward Incidents (SUIs)
Reference Number POL/N&G/0022
Policy and procedure for the reporting and management
of Serious Untoward Incidents (SUIs)
Version number 1.1
Document Type Policy
Original Policy Date February 2011
Date approved February 2011
Effective date February 2011
Approving body Safety Committee
Originating Directorate Directorate of Nursing and Service Transformation
Last review date Na
Next review date February 2014
Reviewing body Safety Committee
Document Owner Patient Safety and Clinical Risk Manager
Date superseded New policy
Confidentiality Management in Confidence / Staff in Confidence /
Commercial in confidence / Unrestricted
Keywords Incident, SUI, Risk
Signature of Chairman of Approving Body
Name / job tile of Chairman of approving
Signed paper copy held at (location):
POL/N&Q/0022 Version 1.1 Page 1 of 45
Policy and procedure for the reporting and management of Serious Untoward Incidents (SUIs)
1 Introduction 4
2 Purpose 4
3 Duties 5
4 Reporting and Management of SUIs 10
5 Key Performance indicators 14
6 References 16
7 Associated Documentation 17
Procedure for the reporting, management and
Appendix A investigation of Serious Untoward Incidents (SUI‟s) –
Community Health Services Only
Appendix B Protocol for Investigation and Review of Serious
Untoward Incidents (SUI‟) – Acute Services only 27
Appendix C Procedure for setting up a hot line/help line (both Acute
and Community Health Services) 31
Appendix D Escalation to the Strategic Health Authority (SHA) 32
Appendix E Staff support letter 34
Appendix F Guidance on developing and writing statements 35
Appendix G Definition of a RIDDOR reportable incident 37
Appendix H NPSA‟s List of Never Events 39
Appendix I Rationale to support the provision of Complaints, Litigation,
Incidents and PALs Reports 41
Appendix J Being Open Letter/Letter of Apology 45
Appendix K Telephone enquiry record (major incident) 46
POL/N&Q/0022 Version 1.1 Page 2 of 45
Policy and procedure for the reporting and management of Serious Untoward Incidents (SUIs)
Document Control Information
Version control table
Date of issue Version number Status
February 2001 1.1 Approved
Table of revisions
Date Section Revision Author
POL/N&Q/0022 Version 1.1 Page 3 of 45
The NHS is accountable to the public for delivery of health care services and
in this context, County Durham and Darlington Foundation Trust (CDDFT)
need to monitor all safety issues and incidents to ensure that learning is
shared across the organisation and partner organisations as appropriate.
It is important to stress that CDDFT is committed to a policy of „fair blame‟.
Fair blame means that the organisation:
Operates its incident reporting policy in a culture of openness and
transparency, which fulfils the requirements for integrated governance.
Maintains a focus on continuing, demonstrable improvements in the quality
of the patient‟s care experience.
Adopts a systematic approach to an incident when it is reported and does
not rush to judge or „blame‟ without understanding the facts surrounding it.
Encourages incident reporting in the spirit of wanting to learn from things
that go wrong and improve services as a result.
The purpose of this policy is to provide guidance, information and procedures,
which if followed, will ensure that CDDFT complies with legislation, and the
requirements of the National Patient Safety Agency (NPSA) with regard to
incident reporting generally, but in particular the reporting, notification and
investigation of „Serious Untoward Incidents‟ (SUIs).
The document sets out CDDFT‟s approach to the identification, reporting and
management of serious untoward incidents. The scope of this document is
specific to „Serious‟ Untoward Incidents including „Near Misses‟. This policy
relates to the Policy and Procedure for Managing Untoward Incidents and
A number of principles underpin this policy:
The accountability for development and approval of this policy rests
with the Board of CDDFT.
The Board of CDDFT are committed to an open and accountable
incident reporting culture which includes the implementation of the
principles of „Fair Blame‟.
CDDFT accepts its responsibility for providing safe and secure
environments for patients, staff and visitors. In order to achieve and
maintain high standards, it is necessary to have early warning of actual
and potential deficiencies in the systems set up to manage the many
categories of risk to which healthcare organisations are exposed.
CDDFT will encourage comprehensive reporting of all situations,
events, acts, errors or omissions (including hazards and near misses),
POL/N&Q/0022 Version 1.1 Page 4 of 45
which have (or might have) caused avoidable harm, loss or damage to
any person or property.
Formal disciplinary hearings will only be invoked following an incident
where there are repeat occurrences involving the same person where
their actions are considered to contribute towards the incident; where
there has been a failure to report an incident in which a member of staff
was either involved or about which they were aware (failure to comply
with CDDFT Policy and Procedure); the action causing the incident is
removed from acceptable practice or standards in view of CDDFT
and/or professional regulatory body; there is proven malice or intent.
Staff will be encouraged to use support mechanisms such as
counselling and/or training.
CDDFT will ensure that SUIs are identified, openly investigated, lessons
learned and promptly applied. These lessons will be applied across CDDFT
and may form the basis for inclusion in subsequent Clinical Audit and Clinical
This Policy is intended to complement CDDFT Policy for Reporting and
Management of Incidents and Near Misses, NHS County Durham and
Darlington PCT‟s Policy and Procedure Guidance for Reporting and
Management of Serious Untoward Incidents (SUIs) CG001, and National
Patient Safety Agency‟s (NPSA‟s) National Framework for Reporting and
Learning from Serious Incidents Requiring Investigation 2009.
This policy should be used by all staff in CDDFT including students, voluntary
staff, those on honorary contracts or trainees on temporary placements.
3.1 All Staff responsibilities
All staff, including temporary and agency staff, are responsible for complying
with organisational policies and procedures. Failure to comply may result in
disciplinary action being taken.
3.1.1 Basis of allocation of responsibility
The Health & Safety at Work Act 1974 places a Duty of Care on every
employee, a responsibility to maintain safe systems of work, to take
care of their own safety and that of colleagues and all other persons
who may be affected by their acts or omissions.
This means every individual employee is responsible for reporting
incidents in which they are involved, or of which they have
knowledge, and any situation they think is potentially dangerous
or harmful to a patient or member of staff.
Reporting SUIs does not absolve individuals of their responsibility to
identify actions to prevent reoccurrence.
POL/N&Q/0022 Version 1.1 Page 5 of 45
i) When an incident occurs, it is the responsibility of the employee
to take immediate action to ensure the situation is made safe
and to preserve the scene if a crime is suspected. The employee
should also, depending upon the nature of the incident, consider
involving the local police (only after consultation with PSM).
ii) Employees have a duty to report all SUIs both verbally in the first
instance and then as per the relevant procedure. After the
incident employees reporting the incident or those involved in it
are required to discuss the matter with the person leading the
investigation, support improvements to working practices
highlighted by incident investigations, bring any training needs to
the attention of their line manager and attend any necessary
3.2 Individual / Nominated Responsibilities
3.2.1 Chief Executive
The Chief Executive, as the accountable officer, has overall responsibility for
ensuring that effective arrangements are in place for the reporting,
management and learning from incidents.
3.2.2 Trust Board
The Board has overall responsibility for setting the strategic context in which
organisational policies and procedures are developed, and for establishing a
scheme of governance for the formal review and approval of policies.
3.2.3 Director of Nursing and Service Transformation
The Director of Nursing and Service Transformation is the Lead Officer for the
management of all SUIs in line with the National Patient Safety Agency‟s
(NPSA) National Framework for Reporting and Learning from Serious
Incidents Requiring Investigation 2009. This officer ensures that mechanisms
are in place to report all SUIs to the Strategic Health Authority (SHA).
3.2.4 Assistant Director of Clinical Assurance
The Assistant Director of Clinical Assurance will deputise in the absence of
the Director of Nursing and Service Transformation.
3.2.5 Patient Safety and Clinical Risk Manager
The Patient Safety and Clinical Risk Manager will deputise in the absence of
the Assistant Director of Clinical Assurance.
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3.2.6 Executive Directors
All Executive Directors are responsible for:
i) Ensuring the implementation of this policy and procedure within
their area of responsibility.
ii) Ensuring that necessary training or education needs are
identified and resourced in order to implement the policy.
iii) Ensuring that the above are built into the delivery planning
iv) Ensuring that mechanisms are in place for the regular evaluation
of the implementation, effectiveness and management of this
policy within their directorate.
3.3 Assistant Directors/Clinical Divisional Managers/Service Managers (or
Are responsible for:
Ensuring that staff are supported and encouraged to report SUIs.
Reviewing all incidents within their services to ensure that all serious
incidents have been identified as such.
Ensuring the investigation procedure is followed within their service
areas and within agreed timescales.
Ensuring their staff have access to and comply with all relevant
guidance and advice within the policy.
Implementing agreed training or education methods or programmes in
respect of this policy.
Establishing mechanisms for regular evaluation of the implementation
and effectiveness of this policy within service(s).
Ensuring corrective action is taken to prevent the incident occurring
again and that staff are advised of corrective actions taken and why
this was necessary. This may involve liaison with other senior
managers and specialist staff.
Notifying the policy co-ordinator should any aspect of this policy be
considered to be in need of revision.
Disseminating learning from incidents to staff and also ensuring an
audit trail is available should it be required.
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Ensuring they collate and preserve evidence to show how
implementation of action plans has been achieved.
Providing specialist advice and support to investigation leads with the
investigation of SUIs and subsequent reports and action plans.
Ensuring that the Risk Registers are amended where necessary to
include identified risks.
3.4 Patient Safety and Clinical Risk Officers (PSCROs)
PSCROs have a key role in the management of SUIs. They will:
i) Take advice from the Director of Nursing and Service Transformation
about the classification of all SUIs and report those which meet full
SHA reporting criteria on to the STEIS database.
ii) Notify other relevant teams that an SUI has occurred, if notified verbally
before the incident is reported on Safeguard.
iii) Forward relevant investigation reports and action plans to SHA.
iv) Provide specialist advice and support to investigation leads on
investigation of SUIs and subsequent action plans.
v) Provide information for the Safety Committee (SC) about SUIs, the
organisational response and an update on implementation of each SUI
action plan by the services.
vi) Produce analytical reports in partnership with colleagues from the
Patient Advice and Liaison Service (PALS) and Complaints which will
be presented to Clinical Quality Committee, the CDDFT Board and
relevant managers when necessary.
vii) Ensure that the SUI is reported to other key people in the organisation
e.g. legal services.
viii) Oversee and coordinate the implementation of this policy and
ix) Produce and ensure the dissemination of patient safety alerts
generated by lessons learnt from SUIs.
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3.5 Health and Safety/Non Clinical Risk Team
Specific Responsibilities include:
i) Contributing to the achievement of policy by assisting managers with
health and safety incident management where appropriate, lead the
investigation on H&S related SUIs and produce reports and action
ii) Ensure that SUI reports and action plans are submitted to H&S
iii) Review of all health and safety incidents to ensure that all serious
health and safety incidents have been identified as such and the
relevant processes actioned.
iv) Advise Patient Safety and Clinical Risk Manager and Patient Safety
and Clinical Risk Officers of any H&S SUIs which fulfil STEIS reporting
v) Inform relevant external agencies of SUIs, where appropriate.
vi) Ensure lessons learned from H&S SUIs are disseminated.
3.6 Information Governance Manager/Pharmacy/Medicines Management
Team/Medical Devices Lead
Specific responsibilities include:
i) Assisting managers with investigations and action plans in response to
incidents related to their speciality.
ii) Advise PSMs of any SUIs which fulfil STEIS reporting criteria.
iii) Informing other relevant agencies e.g. Information Commissioner‟s Office/
CD Officer/ MHRA of any incidents which fulfil criteria, and liaising with
them on any investigations and ensuring any subsequent required actions
iv) Initiating production of any necessary analytical reports.
3.7 Safety Committee (SC) Members
Nominated members of the SC have specific responsibilities which include:
i) Presenting new SUI reports and action plans on behalf of their
ii) Presenting completed action plans on behalf of their represented services
for „sign off‟ by the committee
POL/N&Q/0022 Version 1.1 Page 9 of 45
iii) Reading, reviewing and commenting upon SUI reports and action plans
presented to the PSC.
iv) Disseminating outcome lessons and themes from across the range of
services to their represented services.
4 Reporting and Management of SUIs
Please see Appendices A and B
An incident is an unexpected, unplanned and/or uncontrolled event.
“Serious Untoward Incident” (SUI)
An incident occurring on NHS premises or non NHS premises but always
related to the provision of health care wherever it is delivered and which
involves one or more than one of the following:
Death, serious injury or harm to patients, staff or the public
Significant loss or damage to property or the environment
Likelihood of significant public concern
A „near miss‟, or even a low impact incident but one which has the
potential to contribute to serious harm.
Important note If there is any doubt about the definition of the incident,
individuals are encouraged to discuss the matter with their line manager and
Patient Safety and Clinical Risk Manager (PSCRM) without delay.
A Near Miss is an incident which is prevented by an intervention but had the
potential to progress to serious harm.
“Root Cause Analysis” (RCA)
Root Cause Analysis is a method for investigating patient safety incidents and
can help to identify what, how, and why patient safety incidents have
happened. It is then possible to use analysis to identify areas for change,
develop recommendations and look for new solutions. For further explanation,
please see the RCA Resource Pack.
Contributory Factors are factors that either influenced or caused a single
event or chain of events that contributed to an incident. The factors may have
had either a negative or a positive effect, e.g. some may have mitigated or
minimised the outcome of the incident.
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Safeguard is a risk management system, used by community health
services, which incorporates the incident reporting function.
“Trigger Notification” (Safeguard)
An e-mail communication regarding an incident sent via the Safeguard
Datix is a risk management system, used by acute services, which
incorporates the incident reporting function.
4.2 Escalation to the Strategic Health Authority (SHA)
The Director of Nursing and Service Transformation as lead officer for
managing all SUIs, will determine whether the SUI is reported to the Patient
Safety Team at the SHA via the Strategic Executive Information System
known as ‟STEIS‟
Please see Appendix D
4.3 Investigation of SUIs
Once an incident has been identified as being serious (SUI, see 6.0) and has
been reported as such, the Clinical Divisional Manager must identify a
suitable member of staff to carry out an investigation using RCA, to find out
why the incident occurred to prevent a similar incident occurring again, and to
enable shared learning.
Please see Appendices A and B
4.4 Additional Requirements
CDDFT is committed to creating a culture and environment which encourages
workers to feel able to raise concerns sensibly and responsibly without fear of
victimisation. The Trust operates a systematic method for staff to raise
concerns in a way that is consistent with the Public Interest Disclosure Act
(PIDA). This process is described in HR Policy „Raising Concerns (Whistle
4.4.1 Assistant Directors, Senior Managers and Heads of Service need to
consider the following:
If the incident has implications for an individual/patient being cared for,
that individual/patient should be informed about what has happened
and appropriate support should be offered to them.
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Where appropriate the individual/patient‟s family, with the patient‟s
permission, should also be informed about the incident.
CDDFT has adopted the National Patient Safety Association (NPSA)
„Being Open‟ guidance. This guidance encourages staff to be open,
honest and apologise to patients and families when mistakes are made
and is reflected in CDDFT‟s policy on „Being Open‟.
The appropriateness of writing a letter of apology to the patient. A
template letter is provided (Appendix J).
4.4.2 It is the responsibility of the line manager in conjunction with the Head
of Service to involve HR as soon as there is any indication that the
Disciplinary Procedure maybe invoked (Appendices A and B).
4.4.3 All „Never Events‟ (Appendix H) must be reported immediately to the
Director of Nursing and Service transformation.
4.4.4 If a SUI occurs as a result of a failure of plant, machinery, medical
equipment or other equipment, the AD of Clinical Assurance and Health and
Safety/Non-Clinical Risk Manager must be notified. Likewise, these members
of staff will also need to know if the incident has led to an adverse reaction
relating to supplies or food; or as a result of a breach of the Health and Safety
at Work act 1974 and associated regulations.
4.4.5 The Head of Communications should be notified if it is considered that
the incident may attract media interest.
4.4.6 The Senior Manager in the service where the incident has occurred
has a key responsibility to carry out a de-briefing meeting with the staff
involved as soon as possible after the incident. The senior manager or line
managers should then de-brief other staff and associated team members
about what has occurred in their service. This should then be recorded on the
„RCA report and action plan‟ form.
4.4.7 The Senior Manager may also wish to consider whether a chaplaincy
service should be provided to offer staff or relatives support if this is
4.4.8 Standing Financial Instructions must also be followed in all cases.
4.5 Commissioning PCT
CDDFT is required to report serious incidents to the Commissioning
PCT and provide assurance that „best practice‟ incident management
and investigation arrangements are in place. In order to fulfil this
requirement, assurance that SUI reports and action plans have been
fully implemented will be provided to the Commissioning PCT through
the Clinical Quality Review Group.
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CDDFT will provide SUI 24/72hr update reports on request from the
All „Never Events‟ (Appendix H) must be reported immediately to the
Commissioning PCT by the Director of Nursing and Service
Details of SUIs should be shared with the National Patient Safety
Agency rapidly via the National Reporting and Learning System
Consideration should be given to informing other relevant external
4.6 Media and Public Interest Protocol
All media enquiries will be handled from the Chief Executive‟s office.
Press statements will be coordinated, when appropriate, with the Head of
Corporate Affairs. In the event of a serious criminal incident where the police
are informed, any press statement will be prepared with the police press
officer. Any statement relating to a prisoner will be handled by the Prison
The media will not be given any information with regard to personal injury or
information until the patient; their relatives or staff injured have been informed.
No information will be given without prior agreement of the individuals
involved. There will be due regard for patient confidentiality when drafting
press statements. In cases where there is potential for a claim to be brought
against the Trust, the NHS Litigation Authority will need to be involved in the
preparation of any press statements.
Information given to the media will concentrate on the fact of the incident and
where possible its potential consequences, but personal speculation about the
cause of the incident will be avoided.
Important note: Any member of staff, who takes a call from the media should
ask the caller to contact the Chief Executive‟s Office.
In the event of large numbers of patients being involved, a help line may be
„Out of hours‟ media enquiries
In the evenings and at weekends, a Senior Manager and Executive Director of
the Trust are on call. If the on call Senior Manager or Executive Director need
advice on handling a difficult media enquiry they can request advice from the
Strategic Health Authority Communications Department, via (0191) 2106464.
POL/N&Q/0022 Version 1.1 Page 13 of 45
4.7 Help line/Hot line
If the incident warrants setting up a hot line/help line for members of the public
to contact, the agreed procedure should be implemented (Appendix C).
4.8 Implementation and Training
Specific training has been identified as relevant for this policy. This training is
provided by the Patient Safety Team and includes Risk Management, Incident
reporting, Being Open and RCA training.
So that all staff can understand the importance of the Incident reporting system
the Trust will ensure that staff are trained to the appropriate level.
Trust Board members and senior managers attend training appropriate to their
identified needs on a yearly basis.
All managers or staff involved in investigating incidents must undergo training
on root cause analysis incident investigation techniques and risk grading. This
training consists of a 1 day programme based on the NPSA Root Cause
Analysis methodology. The objectives of the course are to:
Increase the understanding of the theory underpinning RCA
Provide candidates with an overview of the RCA process
Provide skills in some RCA Tools
Demonstrate the advantages of using a systems-based approach to
patient safety incidents.
Safety teams will receive appropriate specialist training as identified in personal
All other staff groups will receive information on the risk management
processes and how to report incidents on the Trust induction day.
Additional training can be provided to departments / divisions by contacting the
relevant safety/risk manager (Clinical or Non-Clinical)
5 Key Performance Indicators
It is essential that organisations put in place effective controls to ensure employees
have read, understood and work to agreed policies. Within community services,
policies are distributed through the „Safeguard‟ system.
This policy will be reviewed on a 3 yearly basis unless national, regional or
professional bodies require an earlier update.
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The effectiveness of this policy will be reviewed by the following:
Discussion and identification of potential actions of issues raised at the
appropriate risk related group (i.e. Health & Safety, Security, Patient Safety
Number of incidents reported via the IR1 system
Number of claims following an incident
Number of complaints
Number of incidents benchmarked against other Trusts using the ERIC
A report outlining the above will be forwarded to the Trust Board via the Risk
Management Committee on a quarterly basis and subsequent action plans
developed and monitored.
The following mechanisms and processes will be adopted within CDDFT to
maximise learning opportunities from incidents.
Learning at individual and service level
All staff should use incidents as the basis for reviewing their own professional
practice on an individual or collective basis.
Once an immediate remedial action has been implemented, the team or department
should meet to review current practice in the light of experience.
The review must consider practice or procedural issues and staff development
issues, patient, public or carer issues and the humanitarian impact of the incident,
policy issues, the use of the „risk assessment‟ process.
Members of the PSC, Health and Safety Committee and Information Governance
Committee have a specific responsibility disseminate outcome lessons and themes
from across CDDFT to their represented services.
Organisation wide learning
The Safety Committee will be made aware of SUI incidents that have previously
been subject to the SUI management procedure, and have subsequently re-
occurred. In addition to learning at local level, CDDFT will share learning as follows:
Integrated Complaints, Litigation Incidents & PALS reports will be forwarded to the
Safety Committee for observation and scrutiny.
Depending upon the nature of the SUIs, internal Safety Alerts will be developed by
the relevant team and disseminated across the organisation.
In order to strengthen learning and minimise future risks, a regular lessons learned
bulletin will be produced and circulated to all CDDFT staff.
POL/N&Q/0022 Version 1.1 Page 15 of 45
1. NHSLA „Risk Management Standards for Acute Trusts” April 2007. Available
2. Department of Health 2001 “Building a Safer NHS for Patients” HMSO
London. Available at
3. ALARM/UCL 1999 “A Protocol for the Investigation and Analysis of Clinical
Incidents” ALARM, London.
4. Health and Safety Executive (HSE) The Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations 1995 (RIDDOR), HSE Books. Available
5. Connecting for Health, Information Governance Toolkit
6. National Patient Safety Agency‟s
7. Health & Safety at Work Act 1974
General duties of Employers and Employees. Requirement that employers
assess and manage risks to health and safety.
8. Human Rights Act 1998
Rights and freedoms protected under the European Convention on Human
Rights. It is unlawful for public authorities to act in a way that is incompatible
with a Convention Right.
9. Freedom of Information Act 2001
All information held by public authorities is subject to disclosure under the
Freedom of Information Act 2000 (FOI). From January 2005 the Act allows
anyone, anywhere to ask for information held by organisations, although
some information, such as patient identifiable information, is exempt.
10. Data Protection Act 1998
The Data Protection Act 1998 became law in March 2000. It expands
on the 1984 Act to include manual as well as electronically held
records. It also encompasses the Access to Records Act 1990 where it
applies to living people. There are eight principles put in place by the
Data Protection Act 1998 to make sure that information is handled
11. Equality Act 2006
Provisions relating to Human Rights and discrimination on grounds of race,
religion or belief sexual orientation; sex; amends the Disability Discrimination
POL/N&Q/0022 Version 1.1 Page 16 of 45
7 Associated Documentation
Cross References (internal):
Risk Management Strategy
Risk Management Operational Policy
Health and Safety Policy
Violence and Abuse Policy
Medical Devices Policy
Infection Control Manual and Policies
Major Incident Plan
Being Open Policy
Supporting staff involved in potentially traumatic or stressful work related
Security Incident Management Policy (POL/HIG/0010)
POL/N&Q/0022 Version 1.1 Page 17 of 45
PROCEDURE FOR THE REPORTING, MANAGEMENT &
SERIOUS UNTOWARD INCIDENTS (SUIs)
(COMMUNITY HEALTH SERVICES ONLY)
Reporting and Management
1. The first priority when a SUI occurs is to ensure the needs of individuals
affected by the incident are attended to, including urgent clinical care. A safe
environment should be re-established, all equipment or medication retained
and isolated, and relevant documentation copied and secured to preserve
evidence and facilitate investigation and learning. If a crime is suspected, the
scene/environment should be preserved.
2. An employee must report a SUI immediately or as soon as it is discovered to
the relevant line manager and a Patient Safety & Clinical Risk Officer
Manager (PSCRO). The PSCRO will be responsible for notifying the Clinical
Director of Community Services and a HR Manager. The line manager will be
responsible for notifying the Clinical Divisional Manager/Head of Service
(where the incident has occurred). The Clinical Divisional Manager/Head of
service must notify their appropriate service director depending upon the
nature of the incident.
3. Depending upon the features of the SUI, it may be necessary to involve the
local police. It may be difficult to decide about police involvement and it should
always be discussed with a PSCRO in any case.
Police involvement should be considered when it is known there is one or
more than one of the following:
deliberate harm caused to patient or employee
loss of identifiable data
violence or the threat of violence
NB – this is not an exhaustive list and there may be other instances where
police involvement is recommended.
4. If the incident is potentially a child or adult safeguarding concern, the relevant
documents should be referred to and a safeguarding alert raised (CO 033
NHS Safeguarding Children policy, CL 063 Safeguarding Adults at Risk of
Abuse policy, Clinical Governance and Adult Safeguarding flowchart (NPSA
„National framework for reporting and learning from serious incidents requiring
Please see flowcharts for both „in‟ and „out of normal‟ working hour‟s
POL/N&Q/0022 Version 1.1 Page 18 of 45
5. Once the employee has reported the incident verbally, an on-line incident
reporting form should be completed through the Safeguard system within
24hrs of the incident being discovered.
6. Once the reporter has completed and submitted the on-line incident form, a
„trigger notification‟ will be automatically sent to the:
Reporter‟s line manager and other managers depending upon the
nature of the incident as described below:
Contractor /Visitor Accident Health & Safety/Non Clinical Risk Team
Staff Accident /Incident
Staff Car Accident
Staff Ill Health
Violence and Aggression
Unexpected Death Patient Safety Team
Information Management & Technology Records Manager/Information
Information Governance Governance
Documentation and record keeping Patient Safety Team
Consent, communication & confidentiality
Medication general Medicines Management Team
Medication controlled drugs Patient Safety Team
Medical devices/equipment Medical Devices Lead
Patient Safety Team
Pressure sores Patient Safety Team
Clinical Care (implementation/monitoring)
7. On receiving a trigger notification, the line manager should complete and
submit their section of the incident form within 48hrs. Other relevant service
managers on receiving a trigger notification should follow their agreed
8. The Director of Nursing and Service Transformation as Lead Officer for
managing all SUIs, will decide whether the SUI is reported to the SHA Patient
Safety Team via the Strategic Executive Information System known as
Please see Appendix D.
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9. An investigation should be carried out and the following adhered to:
i) A lead investigator should be appointed by Clinical Divisional Manager.
ii) The RCA resource pack (Appendix ) should be consulted and an RCA
undertaken. The RCA must be carried out within 20 working days of
the incident being discovered and should involve the lead investigator,
Staff members involved, any other relevant persons, and can be
facilitated by a PSGM.
iii) The „RCA investigation report and action plan‟ template (Appendix )
should be completed by the lead investigator and timescale for action
plan completion agreed.
iv) The completed report and action plan should be submitted to the
Patient Safety Team for initial quality check.
v) A review meeting must take place within 10 working days of the RCA
investigation to assess the quality and validity of the report and action
plan and to decide whether any further action is required e.g. additional
training or further investigation under NHS Darlington‟s Discipline
policy. Review meeting attendees should include lead investigator,
PSCRO and HR representative (if necessary). Attendees may change
according to the nature of the incident.
NB Unless there are extenuating circumstances the internal investigation
process for a SUI will be completed within 60 working days.
Once the RCA report and action plan are finalised, they should be:
vi) „Signed off‟ by Clinical Divisional Manager/Service Manager as they
receive the reports and decide on any further action to ensure that the
content is appropriate, clear, concise and timely.
vii) Submitted to the Patient Safety Team (PST) 14 days before the date of
the next SC meeting for final quality check and necessary
viii) Submitted to the Safety Committee (PSC) for review.
PSC takes place once a month. Reports and action plans should be
submitted to the next SC meeting following the RCA investigation.
Any delays must be accounted for to the SC.
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If the report and action plan are not received by the PST 14 days
before the next SC meeting, escalation will occur as follows:
- Delay of 4 weeks – Clinical Divisional Manager will be contacted
- Delay of 8 weeks – Letter from Clinical Director of Community
Services to Clinical Divisional Manager advising report and
action plan to be submitted to following SC meeting.
Action Plan Implementation and Monitoring
ix) The action plan should be implemented according to the agreed
timescale. An update on the progress of the action plan will be
presented by a PSCRO to the SC on a monthly basis to ensure
implementation timescales are met. This also provides the opportunity
for advice/guidance to be sought on possible implementation
A similar escalation process to above will be adopted if the action plan
is not completed within the agreed timescale.
x) Completed action plans should be signed by Clinical Divisional
Manager and re-submitted with supporting evidence showing how the
action plan was implemented, to the PST 14 days before the next SC
meeting final checks. The action plan will be re-submitted to the SC
and should be presented by the relevant SC member for final „sign off‟
by the committee. The SC will decide whether or not enough action
has been carried out to prevent the incident recurring or reduce any
residual risk as far as possible.
xi) Managers must ensure they collate evidence to support how action
plan implementation has been achieved.
xii) Lessons learned from the incident investigation will be disseminated
throughout CDDFT, the wider organisation and with external
organisations including the SHA and NPSA.
POL/N&Q/0022 Version 1.1 Page 21 of 45
REPORTING, MANAGEMENT AND INVESTIGATION OF SUIs
„IN WORKING HOURS‟
SUI occurs (definition 2.0)
Reporter makes the situation „safe‟ and
preserves equipment, medication and documentation
PSCRO informs Clinical
Reporter completes on-line Reporter informs line manager Director of Community Services
incident report form via and PSCRO immediately and HR Manager and if relevant
Safeguard (within 24 hrs) (verbally) other service managers (e.g.
Health & Safety). Information
gathering to begin in
conjunction with service
Line manager informs Clinical Divisional manager using probing
Manager/Head of Service and AD from the questions
Line manager receives service where the incident occurred
Safeguard incident report
trigger and completes the
incident report form (within
48hrs). Other relevant
services also receive the Clinical Divisional Manager informs
trigger notification. appropriate service Director depending upon
nature of incident.
NB: All this
happens within Incident discussed with Clinical Director of Community Services, CEO or Deputy, and Service
24 hours except Director.
Decision made as to whether the
incident is reportable to the SHA via
YES - SUI IS reportable to
SHA and Service Director/AD NO – SUI does NOT fulfil SHA
informed reporting criteria and Service
PSCRO places the SUI
incident description on
the SHA STEIS database Consideration given to:
Involvement of Commissioners
Informing the patient/family/relatives
Any disciplinary issues and HR involvement
POL/N&Q/0022 Version 1.1 Page 22 of 45
Clinical Divisional Manager appoints Lead
SUIs reportable to SHA
are updated on STEIS
database by PSCROs as RCA conducted within 20 working days. High
appropriate. Lead level risks are rapidly identified to PSCROs/H&S
Investigator and PSGM
required by SHA
RCA report and action plan drafted and timescale
for completion of action plan agreed
Consideration given to
Completed report and action plan submitted to producing Patient
Patient Safety/H&S Team for initial quality check. Safety/H&S Alert with
key learning from SUI.
Review meeting takes place within 10 working days of the RCA
investigation to assess quality and validity of report and action plan and
decide whether further action required
NB Reports and action
plans should be submitted
to the next SC meeting Report and action plan signed off by Clinical
following the RCA Divisional Manager
investigation. Any delays
must be accounted for to the
Report and action plan Submitted to the Escalation Process
Patient Safety Team (PST)/H&S team by 2
Wednesday of the month If the report and action plan are
not received by the PST by the
Report and action plan nd
2 Wednesday of the month,
forwarded to SHA (within escalation will occur as per
45 or 60 working days procedure (Appendix A)
dependent upon incident
Report and action plan Submitted to the PSC
grading). For independent for review.
investigations within 26
Update on the progress of the Action plan implemented according to agreed
action plan will be presented by timescale.
a PSCRO to the SC on a
monthly basis to ensure
implementation timescales are Continued overleaf…
POL/N&Q/0022 Version 1.1 Page 23 of 45
Once completed, action plan signed off and re-
submitted with evidence to the PST on 2
Wednesday of the month for final checks.
Action plan re-submitted to SC and presented
by relevant PSC member for final „sign off‟.
Lessons learned from the incident investigation disseminated
internally and externally
AD Assistant Director Text in rectangle = reporting action
CEO Chief Executive Officer
CDCS Clinical Director of Community Services
FSM Functional Service Meetings
H&S Health and Safety
SC Safety Committee Text in oval = point of
PSCRO Patient Safety & Clinical Risk Officer consideration
RCA Root Cause Analysis
SHA Strategic Health Authority
SMT Senior Management Team
STEIS Strategic Executive Information System
SUI Serious Untoward Incident
POL/N&Q/0022 Version 1.1 Page 24 of 45
REPORTING AND MANAGEMENT OF SUIs
„OUT OF WORKING HOURS‟
SUI occurs (definition 2.0)
Reporter makes the situation „safe‟ and
preserves equipment, medication and
Senior Manager On-call is notified
Executive Director On-Call informed by
Senior Manager On-Call
Consideration given to the features of the incident and
decision made about the status of the SUI based on
SHA criteria (in on-call pack)
NO – SUI does NOT fulfil
YES - SUI IS reportable to
SHA reporting criteria
SHA STEIS database
Consideration also given to:
Upload SUI details to SHA Police involvement
STEIS using operating Media protocol
procedure in on-call pack Involvement of
Report incident to Director of Safeguarding
Nursing and Service Any disciplinary issues
transformation and AD of Clinical and HR involvement
Assurance next working day.
Follow SUI reporting procedure Key:
(Appendix A) 9.00am next working day
and alert correct service manager and Text in rectangular box =
PSCRO to escalate incident. reporting action
Text in oval
boundary = point of
POL/N&Q/0022 Version 1.1 Page 25 of 45
SUIs PROGRESSING TO FURTHER INVESTIGATION UNDER DISCIPLINARY
Investigating officer appointed by Within 0 + 33 working
HofS within 3 working days of days of the incident
the RCA review meeting occurring
Within 0 + 53 working
Further investigation involving staff member using days of the incident
principles of disciplinary/capabilities policy occurring
Action Investigation report and recommendations to Within 0 + 58 working
plan manager/HR within 5 working days days of the incident
operational Within 0 + 63 working
recommendations from days of the incident
report implemented occurring
No Hearing Disciplinary Within 0 + 78 working
Hearing days of the incident
Individual Systems Individual Systems
action plan* issues action issues
monitored identified not plan identified not
through PDP picked up in monitored picked up in
and E-KSF RCA through RCA
PDP & E-
signed off and
Lessons Patient Safety
Learned Bulletin Committee
1. Letter of decision to be copied to relevant manager and Head of Service for monitoring
2. Patient Safety Committee monitors all systems related action plans to ensure organisation
3. Clinical Director of Community Services and Clinical Quality to receive outcome of all
hearings in relation to clinical staff (registered and non-registered).
4. Timescales may need to be extended to address
POL/N&Q/0022 Version 1.1 Page 26 of 45
Protocol for Investigation and Review of Serious Untoward
(ACUTE SERVICES ONLY)
This protocol is a framework to facilitate in-depth analysis of and learning from
events where there has been significant harm to or death of a patient.
Aim / Purpose
To ensure in-depth analysis of the incident, claim or complaint
To ensure appropriate experience and expertise is fully applied to the review
To ensure that (in addition to the immediately obvious cause) all the events
leading up to the adverse outcome are considered
To ensure a structured and systematic approach is applied to the review aiding
mapping of the events, a comprehensive investigation and production of a formal
To ensure a consistent (and documented) approach is used to all incidents,
therefore, increasing openness for staff, reducing fear of unknown and creating a
less threatening approach
To facilitate a climate of openness and a blame free approach
To ensure that learning takes place, reducing subsequent / similar risks
To ensure that the findings are applied at all relevant levels
Any incident, claim or complaint which has been categorised as red during the
investigation should be reviewed using this protocol. The protocol may also be used
for other incidents, claims or complaints where the executive team feel that there
may be significant lessons for the organisation.
The Chief Executive or any member of the executive team can request a review of
an incident, claim or complaint.
This decision is taken after considering the incident report, claim or complaint file,
the advice of the appropriate Risk Manager, Complaints or Legal Services Manager,
initial discussion with lead consultants and / or nursing and Para-medical staff.
Who should investigate?
There needs to be a degree of objectivity and independence in the review and for
this reason, in the case of a clinical event, the lead consultant and clinical staff
actively involved in the case may not be involved in conducting the investigation.
POL/N&Q/0022 Version 1.1 Page 27 of 45
The appropriate Risk Manager, Complaints Manager or Legal Services Manager will
be actively involved in the review process with the support of either the divisional
manager, matron for the ward or the Clinical Director or appropriate staff in the case
of a non-clinical incident.
The appropriate Director will advise who will be the lead reviewer and who will assist.
Roles and responsibilities (Duties)
The lead reviewer conducts all interviews and prepares a report for the appropriate
The second reviewer supports the lead at reviewer interviews taking notes and
clarifying points made where necessary.
The lead reviewer is responsible for ensuring that the relevant external agencies
have been notified and where appropriate either consulted or involved in the
The purpose of the review is to learn lessons and, rather than seek to blame
individuals, consider the wider general organisational issues.
The occurrence of an event is not in itself evidence of neglect, carelessness or
dereliction of duty. Only if evidence of repeated poor performance emerges despite
adequate training / retraining will disciplinary action be considered.
If this becomes evident then advice should be sought from the Personnel
Department. The Trust‟s policy on discipline gives more detail on this point.
Clinical Incidents, complaints and claims
The interview questions will need to be tailored to meet the requirements of the
situation. However, an outline checklist to aid the reviewer in formulating the
questions is given at the end of this procedure.
Non-clinical incidents, complaints and claims
The interview questions will need to be tailored to meet the requirements of the
situation. The Director will ensure that the lead reviewer has sufficient expertise to
ask pertinent questions.
A report of the investigation and findings will be produced by the review team. The
report will describe the chronology of events, map the events and put them into
context i.e. (environmental factor, statutory requirements, care management
problems, clinical context and factors, specific and general contributory factors).
The report should include the following:
Statement of what happened
POL/N&Q/0022 Version 1.1 Page 28 of 45
The review team
The nature of the investigation
The root causes
Recommendations (with timescales)
Any audit findings
Once completed the report should be presented to the appropriate director and
reviewed according to the Trust process. The original incident form will be re-graded
as appropriate by the appropriate Manager. Lessons learned will be shared at the
Safety Committee, Health Care Governance Committee and appropriate divisions.
Root Cause Analysis training is available and should be offered to all staff who may
undertake an investigative role.
Further information is available from Clinical Risk Management or the Life Long
All staff may access this training to gain a greater understanding of Root Cause
Analysis, Incident and Staff Accident Investigation.
POL/N&Q/0022 Version 1.1 Page 29 of 45
Flow Chart showing the Communication Procedure following an Incident
Person Patient and/or Relatives/
Next of kin
Consultant Ward Manager/
Clinical Director Senior Nurse Risk Manager/ Legal
Directorate Services Manager
Manager on call
Director of Nursing
or executive on
Media Chief Chairman
has taken place
POL/N&Q/0022 Version 1.1 Page 30 of 45
Incident Investigation- Checklist of Contributory Factors
Please consider each question in turn, in the light of the incident and tick all questions you
Framework Contributory Factors Tick Tick
Factor for for
Org & Man Do you feel that management generally showed appropriate care
Work Did the working environment (e.g. heat, noise, etc) affect you?
Environment Was there adequate and reliable information from all equipment?
Did all the equipment you used work adequately and effectively?
Did you have enough medical and nursing supplies?
Did you have to rely on a new (locum) doctor or (agency)
nurse/midwife whom you had not worked with before?
Do you feel your orientation period to the hospital/speciality/ward
prepared you for this case?
Was your training in using equipment/protocols sufficient for this
Did you have to spend time on non-clinical duties?
Did you have an unexpected or sudden increase in workload?
Did you have to prioritise more than one case simultaneously?
Were there delays in carrying out clinical procedures?
Team Was communication between yourself and other members of staff
Was there any language or cultural problems or
misunderstandings between staff, the patient and the relatives?
Were the case notes available, legible, attributable and complete?
Were the case notes adequately flagged to alert you to risk
Did you have adequate supervision or support?
Was help/advice from another member of staff available at all
Did staff agree about who was in charge either of the patient or the
Individual Do you feel you had enough knowledge and experience to deal
with the problem/complication?
Did you feel tired, hungry or unwell?
Did you feel appreciated and was your morale high?
Do you feel your opinions and competence were accepted,
appreciated and unquestioned?
Task Was there agreement regarding the interpretation of test results?
Were routine tests carried out and the results documented in the
Were test results quickly and easily available?
Was the appropriate person consulted when necessary about the
management of care?
Did you have enough time to spend with the patient explaining
procedures, possible complications and outcomes?
Patient Was the patient/visitor helpful and co-operative?
POL/N&Q/0022 Version 1.1 Page 31 of 45
Please use the following space to expand on any questions
POL/N&Q/0022 Version 1.1 Page 32 of 45
Procedure for setting up a Hotline/Helpline
(Acute & Community Health Services)
In some incidents, such as problems with screening results, it can be anticipated that there
will be multiple enquiries from the public or other stakeholders.
In the event that a large number of patients or relatives are likely to make telephone
enquiries the Trust will consider establishing a “help line”. The Chief Executive or nominated
executive director will authorise the establishment of a help line under the leadership of a
nominated coordinator. The relevant senior managers and clinicians will agree the
information to be given and the number of staff required. Usually senior nursing staff will be
required to staff the phone lines, although this may need to be revised according to the
nature of the incident. All staff answering calls to the helpline will receive a full briefing on the
incident, Trust response and information required to be documented prior to taking any calls.
Consideration will be given to use of an external body such as NHS Direct who have
expertise in this area. In some cases elements of the major incident policy may be
A press release stating the help line number will be drafted and issued via the usual
channels. Help lines will be based at University Hospital North Durham, in the old Trust
headquarters or in the post graduate centre. At Darlington Memorial Hospital the help line
will be established in the Executive Boardroom where multiple telephone lines are available.
A written record of the calls received will be made including a summary of the advice given.
A proforma for this purpose is included at Appendix C, but this may be altered to suit the
requirements of the incident. In agreeing what information is to be divulged by help line staff,
due attention will be paid to data protection. For this reason although e-mail may be used to
communicate internally with staff, external correspondence will be by letter or telephone.
If it is necessary to contact a large number of patients by post, a team led by the
coordinating Executive Director must agree:
The content of the letter to be sent
To whom the letter should be sent
Who should sign the letter
The timing of the letter, including who will liaise with the post room about the volume
and timing of the mail
The timing of any media release
The timing of the opening of a telephone “hot line”
The coordinator will review the number of calls made to the help line and based on the
information the Chief Executive and appropriate directors will declare “stand down” at an
appropriate time. Before stand down is declared arrangements will be made for the receipt of
any further calls relating to the incident and switchboard will be informed of these
POL/N&Q/0022 Version 1.1 Page 33 of 45
ESCALATION TO THE STRATEGIC HEALTH AUTHORITY (SHA)
1. If the Director of Nursing and Service Transformation decides that the SUI is to
be reported to the SHA, this must occur within 24 hours of the incident being
discovered and placed on the electronic STEIS database. On a normal working
day (9am-5pm Monday to Friday), this will be done by a PSM; outside of normal
working hours, by the Executive Director on call.
It is important to note that only those SUIs with features matching the
SHA‟s „reportable‟ criteria will be placed on the SHA STEIS database.
There will be occasions when serious untoward incidents occurring in
CDDFT do not need to be reported to the SHA because the incident does
not meet the STEIS reporting criteria.
2. Once an incident has been reported to the SHA, the „incident grade‟ should be
identified by a PSCRO and agreed in conjunction with the SHA for purposes of
determining the investigation and monitoring approach as follows:
Grade 0 – Notification only. The provider organisation must update the
PCT/SHA with further information within 3 working days of a grade 0 incident
being notified. If within 3 working days it is found not to be a serious incident, it
can be downgraded with the agreement of the accountable SHA/PCT.
Grade 1 – RCA required within 45 working days from the date the incident is
notified to the PCT/SHA.
Grade 2 - RCA required within 60 working days from the date the incident is
notified to the PCT/SHA.
For further information on incident grading please see:
NPSA National Framework for reporting and learning from serious incidents
requiring investigation, winter 2010 - www.nrls.npsa.nhs.uk/patientsafetydirect
3. The PSCRO should notify by e-mail the following members of staff that an
incident has been reported via STEIS - the Chairman, Chief Executive, relevant
Clinical Director and AD of Clinical Assurance.
4. If the Director of Nursing and Service Transformation decides that the SUI is not
reportable to the SHA STEIS, it will continue to be managed by CDDFT and
investigated in exactly the same way as STEIS reportable incidents. The only
difference being that this type of SUI does not meet the STEIS criteria and is
therefore not externally reportable.
5. Where SUIs are STEIS reportable, PSCROs should ensure regular contact is
made with the SHA regarding the updated position and should have updates
available upon request for 24/72hr reports. It is therefore important that the
relevant line manager, lead investigator and PSCRO remain in close contact so
that new information can be shared and reported on.
POL/N&Q/0022 Version 1.1 Page 34 of 45
6. Out of normal working hours, the Senior Manager on call is responsible for
ensuring that the Executive Director (ED) on call is made aware of the incident.
The ED will inform the Chief Executive. The ED will then consider the features of
the incident and decide about the status of the SUI based on SHA criteria (in on-
call pack). If the ED decides the incident should be reported to the SHA, then the
SUI details should be uploaded to the SHAs STEIS using the operating
procedure in on-call pack. The Senior Manager for the service where the
incident has occurred should discuss the incident with a PSM at 9.00 am the
following working day, who will in turn report the matter to the Director of Nursing
and Service Transformation. It is also important that the service manager
discusses the incident with their Director by 9.00 am the next working day. The
„In Normal Working Hours‟ reporting procedure must then be followed.
7. The Director of Nursing and Service Transformation as lead officer, where
appropriate, will convene an Incident Co-ordination Group in line with the
„Memorandum of Understanding‟ (described in NHS County Durham and
Darlington‟s CG001 Policy and Procedure Guidance for Reporting and
Management of Serious Untoward Incidents, January 2010).
POL/N&Q/0022 Version 1.1 Page 35 of 45
Staff support letter
As you are probably aware a patient with whom you have had recent
contact/provided care, died unexpectedly/was subject to an adverse event on
I have enclosed a staff guidance sheet for your information which I hope you will find
I appreciate that this is never easy for those concerned. However support is
available to you from your colleagues and managers, and I wanted to take this
opportunity to offer you my support and that of the risk management team.
The Trust promotes an open culture which allows us to work together to make this
process as open and uncomplicated as possible and to learn from what happened
and to help others who might find themselves in the same situation.
If you have any concerns or questions feel free to contact me and I will do my best to
explain what may happen next and any parts of the process you do not understand,
including confirming what is expected from you in terms any further investigations
that may be required.
I hope the information is helpful. If you have any questions, suggestions or
comments, please give me a call on the above number.
Assistant Director of Clinical Assurance
POL/N&Q/0022 Version 1.1 Page 36 of 45
Guidance on the Development and Writing of Statements
Staff are often requested to provide statements in response to complaints,
untoward incidents and claims against the Trust etc. The person providing the
statement may have been directly involved in, or witnessed, a specific event. On
occasion a statement is requested to clarify/confirm normal working practices in a
given situation. When developing a statement it is important to cover all of the
events in question.
Whatever the reason for providing a statement it is important that the Trust has a
standard proforma to assist staff with such a task.
The following standards should be applied whenever possible:
Use Trust headed paper.
Have the statement typed whenever possible. If this is not possible
legibility should be ensured by printing the statement in black ink.
Leave double spacing between each line of text.
Number each page (bottom right of each sheet).
Number each paragraph (left hand margin at first line of each paragraph).
Statement should be single sided.
3. Content of Statements
A statement must be in the words of the witness though assistance can be given
by a third party e.g. Head of Department, Divisional Manager.
The following guidelines should be applied:
The statement should be in narrative form in the first person.
Events should be complete and stated in chronological order.
Events should be timed.
Must provide all of the necessary factual detail and where specific issues
are identified, i.e. via a complaint, respond to each of those issues.
Must sufficiently reference any documents referred to (attach if
The first paragraph should include your full name and contact address e.g.
I, Joe Smith c/o The University Hospital of North Durham, Durham City will
state as follows:-
POL/N&Q/0022 Version 1.1 Page 37 of 45
The second paragraph should include details of your professional
qualifications and employment details e.g. `I am employed by County
Durham and Darlington NHS Foundation Trust and I am a Registered
Qualified Nurse. My qualifications are R.G.N. and I have a Diploma in
Nursing Science. I have worked on surgical Wards for the Trust since
1993 and I am currently employed on a full time basis on Care Ward‟.
Subsequent paragraphs should contain detailed relevant information (in
chronological order) relating to the issue in hand, including the
background to the incident. It is important that you record all timings in
The final paragraph should read, `I believe that the facts in this statement
The statement should then be clearly signed and dated (print and sign
4. Statements Provided in Response to Claims against the Trust
A statement developed as a direct result of a litigation claim is a privileged
document i.e. it cannot be disclosed without agreement of the Legal Services
Manager and/or the Trust Solicitors/NHS Litigation Authority.
The Legal Services Manager and/or the Trust Solicitors to ensure compliance
with the format determined within the Pre Action Protocol must facilitate
development of these statements.
The Front sheet must detail the name of the maker of the statement, version
number, date and number of exhibits e.g. articles, publication and accompanying
5. Further Considerations
If you have been asked to provide a statement on issues that are outside your
expertise/knowledge then you should discuss this with the Legal Services
Statements must omit hearsay, rumour, similar fact and opinion. You should
simply state the facts.
It should be remembered that statements provided for one purpose may be used
for another e.g. statements used for follow up of untoward incidents may be
provided to assist the Complaints Department respond to a formal complaint.
Statements provided during a complaint investigation are can be disclosed in the
event that a claim is made.
County Durham and Darlington NHS Foundation Trust
POL/N&Q/0022 Version 1.1 Page 38 of 45
Definition of a RIDDOR reportable incident
Under the reporting of injuries, Diseases and Dangerous Occurrences regulations
1995 (RIDDOR,) CDDCHS has a legal duty to formally notify the Health and Safety
Executive (HSE) of details of certain incidents that occur in the course or work
The Health & Safety Manager and Health & Safety Advisors are responsible for
ensuring that CDDCHS complies with the requirements of the regulations within the
time limits for reporting:
Immediately for serious and dangerous occurrences.
10 days for an „over three day‟ absence from work for staff injured in a work
It is therefore important to give as much detail on the Incident report, so that the
Trust can fulfil its legal requirements under RIDDOR.
POL/N&Q/0022 Version 1.1 Page 39 of 45
NPSA‟s list of „Never Events‟ 2011 February
Initially in 2010 there was 8 Never Events but this has been increased if a Never Event was
to occur they would be treated as a Serious Untoward Incident and Board need informing
1. Wrong site surgery (existing)
2. Wrong implant/prosthesis (new)
3. Retained foreign object post-operation (existing)
4. Wrongly prepared high-risk injectable medication (new)
5. Maladministration of potassium-containing solutions (modified)
6. Wrong route administration of chemotherapy (existing)
7. Wrong route administration of oral/enteral treatment (new)
8. Intravenous administration of epidural medication (new)
9. Maladministration of Insulin (new)
10. Overdose of midazolam during conscious sedation (new)
11. Opioid overdose of an opioid-naïve patient (new)
12. Inappropriate administration of daily oral methotrexate (new)
13. Suicide using non-collapsible rails (existing)
14. Escape of a transferred prisoner (existing)
15. Falls from unrestricted windows (new)
16. Entrapment in bedrails (new)
17. Transfusion of ABO-incompatible blood components (new)
18. Transplantation of ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or oro-gastric tubes (modified)
20. Wrong gas administered (new)
21. Failure to monitor and respond to oxygen saturation (new)
22. Air embolism (new)
23. Misidentification of patients (new)
24. Severe scalding of patients (new)
25. Maternal death due to post partum haemorrhage after elective Caesarean
Further information at DOH website Never Events.
POL/N&Q/0022 Version 1.1 Page 40 of 45
Rationale to Support the Provision of
Complaints, Litigation, Incidents and PALs Reports
This document outlines the content and process for providing integrated quarterly
Complaints, Litigation, Incidents and Pals reports to the Quality & Innovation
The purpose of the integrated report is to facilitate the analysis of Complaints,
Incidents, Claims and PALs information and allow trend analysis and correlations
between individual collections of data. The report will be future referred to as the
Roles and Responsibilities
The Associate Director of Clinical Assurance is responsible for the initiation of the
The Patient Experience Manager, Legal Services Manager, and Patient Safety and
Clinical Risk Manager will be responsible for validating their data and providing the
appropriate narrative for the report.
The Quality & Innovation Committee will receive and acts on the CLIP report and
ensures themes arising are checked against more detailed data in order to identify
The Quality & Innovation Committee has a responsibility to ensure commitment of
Clinicians is central to effective complaints handling, particularly in terms of
embedding the learning from complaints with the Trust.
Frequency of reporting
The CLIP reports will be compiled on a quarterly basis to take account of the
following time periods:
In addition the above quarterly reports will be supported by an annual report.
Reports will go to the Quality & Innovation Committee. Representatives attending
the Committee act as the conduit for ensuring the conclusions drawn from the CLIP
Report are communicated within the Divisions.
This process will be monitored and reviewed on an annual basis to assess the added
value it provides to the Healthcare Governance Committee.
POL/N&Q/0022 Version 1.1 Page 41 of 45
Content of CLIP Report
The CLIP report will cover:
Complaints, highlighting all Divisional complaints, type of complaint, actions
taken, to identify trends and themes or any shortfalls in the service in a
particular area in order for improvement to take place
Litigation, highlighting all new cases within the trust, covering employer‟s
liability, public liability and clinical negligence cases, once again any themes
or trends will be identified with the directorates involved to allow the
directorate to improve /change systems.
Incidents, highlighting incidents in all areas within the Trust, top ten incidents,
common themes, red and amber incidents, also to highlight open and closed
cases and where possible contributory factors to patient safety incidents.
PALs, highlighting all enquiries via PALs, specifically looking at how the
enquiry came into PALs, common themes, trends and outcomes.
The report will cover Site specific data, directorate specific data and if required
location exact data.
Identification of Risks
The risk matrix is used where risks are derived from the CLIP Report and
subsequently this initiates population as appropriate of Risk Register, Corporate and
Sharing information from lessons learned
Learning at individual and service level
All staff should use incidents as the basis for reviewing their own
professional practice on an individual or collective basis.
Once an immediate remedial action has been implemented, the team or
department should meet to review current practice in the light of
The review must consider practice or procedural issues and staff
development issues, patient, public or carer issues and the humanitarian
impact of the incident, policy issues, the use of the „risk assessment‟
Members of the Safety Committee, Health and Safety Committee and
Information Governance Committee have a specific responsibility
disseminate outcome lessons and themes from across CDDCHS to their
Organisation wide learning
Depending upon the nature of the SUIs, internal Safety Alerts will be
developed by the relevant team and disseminated appropriately.
POL/N&Q/0022 Version 1.1 Page 42 of 45
Where there are lessons to be learned emerging from the CLIP Report,
either local or organisational, direct communication in writing is to be
made with the appropriate Directorate.
In the event of organisation-wide lessons a Trust-wide communication
will be distributed. In addition the lessons learned will feature (where
appropriate) in „Delivering Excellence” (Clinical Governance Newsletter).
A further internal transmission avenue for learning lessons exists via the
directorate Clinical Governance half day events.
Sharing information externally to the Trust
The Trust participates in SHA Networks to ensure cross organisational learning. In
addition there are representatives of whole health economy as members of Clinical
Governance Committee i.e.; PCT reps.
POL/N&Q/0022 Version 1.1 Page 43 of 45
Private and Confidential
It is with great regret that I write to you about the service you recently received from
the ………. (team/service) here at County Durham and Darlington Foundation Trust.
It was never our intention to cause harm to you and your family and we are deeply
sorry for the error, and the harm it has caused.
We always investigate incidents and errors of this type and have a national
procedure to follow which is set by the NHS. I think the investigation will take around
…….days and I am hoping to have the completed investigation report by (date).
The exact cause of the incident will emerge as we go through this investigation
process but the fact that we made certain key errors is already evident. It is clear
(Insert a very short factual explanation of what happened using:
no abbreviations or complex terms
Since some of the errors leading up to this incident are already clear, we will act on
these immediately to make sure that they do not happen again. The investigation
may highlight other errors as we go through the process. County Durham and
Darlington Foundation Trust will draw up an „action plan‟ to show the work we will do
to rectify these errors. I would like you to be involved in helping us to draw up this
action plan if you are willing to do so. I will be in touch with you again about this.
It is natural that you may wish to think about talking to the NHS Patient Advice and
Liaison Service PALS), the NHS complaints service or an Independent Complaints
Advocacy Service (ICAS). If you would like to know how to contact these services,
please do let me know. I would be happy to forward any information to you.
In closing, please accept my sincere apologies for the harm our service has caused.
Words in this template letter are either extracted from or based upon NPSA
Policy „Being Open when Patients are Harmed: Safer practice notice 10‟.
POL/N&Q/0022 Version 1.1 Page 44 of 45
Record of telephone enquiry in the event of a Major Incident or
Major Adverse Clinical Incident
Date Time Call taken by
Name of Caller (Status of Caller e.g. friend, family member or general public etc)
Details of Conversation (Remember this record will be kept, capture the main issues,
questions, concerns raised by the caller AND your responses. Continue overleaf rather than
using a separate sheet.)
Details of the Caller i.e. Address, Telephone No; If Caller is happy to provide
Is follow up contact
Planned Yes No
Requested Yes No
If yes detail who will follow up and within what time frame
End of Call time Signature
POL/N&Q/0022 Version 1.1 Page 45 of 45