Incident - UHB · 4.2.2. The Clinical Governance and Patient Safety quality team will assure the Datix incident form liaising with relevant staff where necessary, and establish whether

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CD Name: Reporting & Management of Incidents Including Serious Incidents Procedure Issue Date:29/05/20 Controlled Document Number: 685 Version: 6.0

Procedure for the Reporting and Management of Incidents Including

Serious Incidents

CATEGORY: Procedure CLASSIFICATION: Governance PURPOSE To set out the procedure for

reporting and investigating incidents. This includes serious incidents investigation.

Controlled Document Number:

685

Version Number: 6.0 Controlled Document Sponsor:

Chief Legal Officer

Controlled Document Lead:

Head of Clinical Governance and Patient Safety

Will this Controlled Document impact upon any contracts held by the Trust?

Yes1 No

☐ ☐

Approved By: Chief Legal Officer On: May 2020 Review Date: May 2023 Distribution:

• Essential Reading for:

• Information for:

All staff

1 If this Controlled Document will have an impact on any contracts held by the Trust, once approved, this will need to be sent to the Procurement Team requesting that it be added to the Procurement Policy Portal

CO

NTR

OLL

ED D

OC

UM

ENT

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Contents Paragraph Page

1 Introduction and scope 3

2 Taking immediate action 3

3 Reporting incidents and near misses 4

4 Incident review 5

5 Incident management 6

6 Approving investigations and monitoring action plans 11

7 Reporting to external agencies 11

8 Incidents raised by other processes 12

9 Incidents raised by other organisations 12

10 Producing reports 13

11 Learning from incidents 14

12 Identifying risks 14

13 Training 14

14 Supporting staff involved in incidents 15

15 Associated documents 16

Appendices

Appendix A Definitions 17

Appendix B NRLS definitions of level of harm 18

Appendix C Working with complaints and concerns process 20

Appendix D Working with legal services process 21

Appendix E Incident investigation process with timeframes 22

Appendix F External agencies reporting 25

Appendix G TRID process 35

Appendix H List of services available to provide staff support 36

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1. Introduction and scope

1.1. The Trust is committed to creating an open and fair culture in which staff are confident about reporting incidents, near misses and concerns. Reporting and investigating incidents, including near misses, is an essential part of reducing risks and improving patient safety. It is important that learning from all incidents, including near misses, occurs and where appropriate, this learning is disseminated across the Trust.

1.2. This procedure sets out the steps that must be followed for the reporting,

investigation and management of all incidents, including near misses, and development of quality improvement plans in accordance with the Trust Policy for the Reporting and Management of Incidents including Serious Incidents.

1.3. This procedure also supports openness and transparency and assures

patients, their families and carers that appropriate review, and learning from incidents are embedded within the organisation.

1.4. Health and Safety incidents requiring investigation, including incidents which

result in staff or public harm, are not addressed in this procedure. Please refer to the Health and Safety Policy & associated procedures.

1.5. Information Governance incidents are not addressed in this document. Please

refer to the IG and IT incident management procedure.

1.6. This procedure may be amended by the authority of the Chief Legal Officer, provided that such amendments are compliant with the Policy.

1.7. Definitions are provided in Appendix A.

2. Taking immediate action

2.1. When an incident occurs all staff are required to ensure the area, patients, staff and visitors are immediately made safe, the appropriate senior clinicians/managers are informed as soon as possible and to report the incident (see section 3 below). This could involve:

2.1.1. summoning assistance and providing emergency medical care; 2.1.2. ensuring that those at risk are moved to a safe environment; 2.1.3. taking immediate action to prevent recurrence; 2.1.4. notifying senior members of staff on duty; and 2.1.5. once an incident form has been submitted (see section 3.6), document

the incident number and immediate action taken in the patient’s medical record.

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2.2. When an incident involves medical devices or equipment, staff should:

2.2.1. ensure that any equipment associated with the incident is secured as evidence;

2.2.2. note any details of all medical equipment involved in the incident; device type, make, model and lot numbers, this should also be documented in the Patient’s Clinical Notes;

2.2.3. retain packaging for details of consumables;

2.2.4. quarantine samples from same box or lot if applicable.

3. Reporting incidents and near misses

3.1. Every member of staff involved or witness to an incident is responsible and accountable for ensuring the incident is reported.

3.2. Following immediate action being taken (see section 2) staff must report the incident using the online incident reporting system, Datix as soon as possible and no later than 48 hours after the incident.

3.3. If staff are not available to complete an incident report (planned/unplanned leave, sickness etc.), the line manager must complete the Incident Report within 48 hours of the incident.

3.4. Where death, a serious injury or a never event has occurred, reporting must

be immediate.

3.5. If the Datix system is not working staff must contact Clinical Governance and Patient Safety with details of the incident.

3.6. Completing an Incident Report Form

3.6.1. Once the appropriate form has been selected staff must:

• ensure they provide a clear account of the incident understandable to a lay person. The incident description must give a clear, concise description of the incident (including key events leading up to it);

• state the immediate action taken to deal with the problem; • ensure that they only provide facts and do not insert opinions; • ensure the information is anonymised; • identify the level of harm to the individual (near miss, no harm,

Low/Moderate/Severe, or death) and where there is harm, detail the injury. Appendix D provides the definition of level of harm in accordance with the National Reporting Learning System (NRLS);

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• do not use abbreviations unless a full translation is included at least once in the narrative

3.6.2. Where individuals are affected by the incident their details need to be

recorded in the ‘Persons Affected’ section of the incident form. Identifying information must not be included in the main description of the incident.

3.6.3. Once the incident report form has been completed the form must be

submitted to the relevant line manager as handler. This is achieved by selecting the line manager or clinical lead (if known) for the area in which the incident occurred as the “Incident handler”.

3.6.4. If the appropriate line manager is not listed, the ‘Datix Administrator’

should be selected and the Clinical Governance and Patient Safety department contacted for advice.

3.7. Automated notifications

3.7.1. Dependent on the incident type, severity and / or category, an

automated push notification is emailed to the relevant staff/senior managers, divisional management teams

3.7.2. For areas where the Prescribing Information and Communication system (PICS) is in place, there is a process in place whereby a set category of incidents as identified by the Medical Director are automatically generated from PICS. Some examples include missed observations from within agreed parameters, PICS archive print and PICS red lines.

3.7.3. An incident form is automatically generated in Datix for these incidents

and sent to the incident handler from the area concerned for action. 4. Incident review

4.1. Actions to be taken by the Incident handler:

4.1.1. Within 7 days of the incident being reported the incident handler will:

a) Review the details of the incident to ascertain the cause of the incident or near miss, and perform local analysis of what happened and why;

b) ensure that they are the appropriate handler for this incident or if required, reassign to a different handler;

c) undertake a quality check to ensure that there is no identifiable information and that the description provides a clear understanding of

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the incident and is written in plain English with appropriate abbreviations;

d) ensure that when a moderate, severe harm or death incident has been reported and the level of harm confirmed, duty of candour should be completed and documented on Datix within 10 working days of the incident being reported as per the Duty of Candour (Being Open) Policy and Procedure;

e) provide feedback to the individuals involved in the incident advising them of any action that has been taken, and ensuring all follow up is documented in Datix which will be automatically emailed to the reporter

4.2. Actions to be taken by the Clinical Governance and Patient Safety team:

4.2.1. The Clinical Governance and Patient Safety team will review all incidents submitted the following working day and categorise them according to the incident details.

4.2.2. The Clinical Governance and Patient Safety quality team will assure the

Datix incident form liaising with relevant staff where necessary, and establish whether escalation for further investigation is required.

5. Incident management

5.1. Determining the level of investigation

5.1.1. Upon initial review, if it is not clear what the level of the investigation should be, or if further clarification is required regarding the details of the incident, the Clinical Governance and Patient Safety team will obtain the further clarity/information about the incident from the reporter/incident handler/relevant clinicians.

5.1.2. Where necessary, a round-table may be held in order to establish further detail. Information on holding an effective round table meeting can be accessed at https://report.npsa.nhs.uk/rcatoolkit/resources/word_docs/Guidance/Guidance_Multi-Professional_Reviews.doc

5.1.3. Where the level of harm reported is severe or death, or, if a near miss had the potential for such harm, the Clinical Governance and Patient Safety team will coordinate the preparation of a case assessment for submission to the CaPRI (Clinical and Professional Review of Incidents) group.

https://report.npsa.nhs.uk/rcatoolkit/resources/word_docs/Guidance/Guidance_Multi-Professional_Reviews.doc

https://report.npsa.nhs.uk/rcatoolkit/resources/word_docs/Guidance/Guidance_Multi-Professional_Reviews.doc

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5.1.4. The case assessment will be submitted to CaPRI for the Medical Director or nominated deputy to confirm the level of investigation required. If it is agreed to be investigated as a Serious Incident (SI) or Internal Serious Incident (ISI) an appropriate clinician is identified to support to the Investigation Officer or relevant lead for the investigation as per the table below:

Type of Investigation

Description

Local investigation Suited to all investigations not requiring complex investigation such as near miss, no harm, and low harm incidents.

Level 1 – Divisional & Executive RCA Level 1 - Concise SI Investigation

Suited to incidents which can be investigated by individuals within the Divisions. These will have Divisional (Divisional RCA) or Executive (Exec RCA) oversight. Cases reviewed at Executive Care Omissions RCA meetings usually involve more than one division, complex patient pathways and/or systemic issues. Incidents will be usually selected by CaPRI based on the potential for wider, systemic learning. Suited to less complex incidents which can be managed by individuals or a small group at a local level. • Serious Incidents involving:

o Grade 3 and 4 hospital acquired pressure ulcers, o Falls causing severe harm o Hospital Acquired Thrombosis (HAT) and o Trust acquired infections causing severe harm

and as per criteria agreed with CCG (see SOP for HAT and L1 SIs)

Level 2 Comprehensive Internal Investigation: Serious Incidents (SIs) and Internal Serious Incidents (ISIs)

Suited to complex issues this includes: • Never events (in line with the Never Events National

Framework); • Incidents resulting in severe or catastrophic harm as per

NHS England’s Serious Incident Framework (SIs); • All incidents which raise a serious concern but may not

have resulted in severe harm and are not a systemic failing (ISIs).

‘Near Misses’ may be investigated as an SI in accordance with the national Serious Incident Framework.

Level 3 Independent

Required where the integrity of the investigation is likely to be challenged or where it will be difficult for an organisation to conduct an objective investigation. Independent

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External Investigation

investigations carried out by an individual external to the Trust and Commissioned by the Medical Director on a case-by-case basis. This category includes investigations conducted by the Healthcare Safety Investigation Branch (HSIB). The Trust can refer via the National Investigations Programme, and, all cases that meet the Each Baby Counts definition are referred to HSIB.

5.1.5. Following confirmation of the level of investigation, the Clinical Governance and Patient Safety team will inform the relevant Divisional and Specialties Management Team, and, if applicable, the identified clinical support of the investigation including the timescales for completion.

5.1.6. The Investigation Team (part of the Clinical Governance and Patient Safety Department) will report Level 2 Investigations to STEIS, the national online incident reporting system, within 2 working days of the incident being commissioned, in line with the Serious Incidents Framework. This automatically notifies the Clinical Commissioning Group (CCG) of the incident.

5.1.7. For level 1 investigations the Governance Facilitation Team (part of the Clinical Governance and Patient Safety department) will report the incidents on STEIS within 2 working days of the incident being commissioned, in line with the National Framework. This automatically notifies the CCG of the incident.

5.1.8. 72 hour updates will be provided to the CCG as requested by the relevant lead in the Clinical Governance and Patient Safety Team.

5.1.9. If it is found during an investigation into a Serious Incident that the incident does not meet the criteria for an SI, a downgrade can be requested from the CCG. This is done by the Clinical Governance and Patient Safety Team using the CCG template following approval by the Medical Director at CaPRI. .

5.1.10. If during an investigation into an ISI the incident is found to meet the criteria for a Serious Incident the Head of Clinical Governance & Patient Safety will seek approval from the Medical Director at the weekly CaPRI meeting for it to be upgraded to an SI. If agreed it is an SI the CCG will be notified as per 5.1.7.

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5.2. Carrying out the investigation

5.2.1. The process and timeframes for level 1 and level 2 investigations and are detailed in Appendix E.

5.2.2. The timeframes to complete each type of investigation and report to the CCG are as follows:

Level of Investigation Investigation completed and draft report written

Submitted to Commissioners

Divisional/Executive RCA

40 working days Not Applicable

Level 1 SI Falls & Pressure Ulcers, IPC

40 working days

60 working days

Level 2 SI* 40 working days 60 working days

*Note: ISIs follow the same timeframe as SIs but are not submitted to the CCG.

5.2.3. All investigations should be carried out using the principles of a structured methodology such as Root Cause Analysis (RCA) methodology and consideration be given to Human Factors.

5.2.4. Divisional investigations will be led by the relevant leads within the specialty and division.

5.2.5. Level 1 investigation will be undertaken by the relevant Specialty management teams. Following completion of the investigation, an appropriate round table will be led by the Division, with support from the specialist team for the purpose of presenting and agreeing the outcome report. The final investigation report will be signed off by the Deputy Chief Nurse after review at the Nursing Incident Quality Assurance Group. The Governance Facilitation Teams will support this process and submit final reports to the CCG within the agreed timeframe.

5.2.6. Level 2 investigations will be reviewed by the Clinical Governance & Patient Safety team and the relevant Divisional Management Team at the Investigation Quality Assurance Meeting (IQAM), where there will be opportunity to quality check the report.

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5.2.7. It is the responsibility of the Divisions, through Divisional Management Teams, to nominate who will attend the draft report discussion at IQAM and to produce an action plan to address the issues identified through incident investigations.

5.2.8. If it becomes apparent that the deadline for completion of a Level 2 investigation and report, will not be met, the Senior Investigation Lead must be notified at the earliest opportunity by the Investigation Officer leading the investigation. The Senior Investigation Lead should be informed of the reason why the investigation is not predicted to be completed on time and a request to apply to the CCG for an extension may be made.

5.2.9. The Senior Investigation Lead will decide on whether or not a request for deadline extension should be made to the CCG, and escalate to the Patient Safety Learning Lead and Head of Clinical Governance & Patient Safety as required. The CCG requires that extension requests should be made at least 1 week prior to the deadline, however the Trust and CCG recommend that requests for extensions be made as soon as necessary.

5.2.10. The CCG can also advise whether a clock stop is appropriate to pause the investigation in the event of unforeseen circumstances which cannot be quickly resolved. A clock stop in particular may be applied for an investigation that is being undertaken by an external body for example HSIB.

5.3. Duty of candour and involving patients and families in investigations

5.3.1. The statutory Duty of Candour (DoC) means that individuals and, where appropriate, their families, must be told openly and honestly when an event happens that causes them moderate, severe harm or death. See the Duty of Candour (Being Open) Policy and Procedure for more information.

5.3.2. Patients and relatives are to be asked if they have any questions they would like answered in the investigation as part of Duty of Candour

5.3.3. Certain investigations (e.g. Level 2 Serious Incidents) warrant an increased involvement of patients and families. In these cases they are to be offered the chance to play an active part in the investigation

5.3.4. 5.4. Documentation on Datix

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5.4.1. For all incidents reported on Datix, outcome of the investigation and lessons learned should be recorded on the Datix form.

5.4.2. For incidents where an RCA investigation has been completed (Divisional, Exec, Level 1 or Level 2), the final report should uploaded on the document section of the relevant incident report form by the Clinical Governance & Patient Safety Team.

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6. Approving Investigations and Monitoring action plans

6.1. Local investigation should be approved by the specialty/department management team who will also ensure that actions identified are implemented in a timely manner.

6.2. Divisional RCA should be approved by the Divisional Management Team and who will also ensure that actions identified are implemented in a timely manner. Exec RCA investigations should follow this approval process prior to being presented at Exec RCA.

6.3. Level 1 SI investigations will be approved by the Deputy Chief Nurse, Quality and action plans populated by the relevant specialist team and quality assured at NIQAM. Any subject to external scrutiny eg Inquests are presented to CaPRI for approval.

6.4. Level 2 investigation reports will be approved by the Medical Director at

CaPRI.

6.5. The Level 2 Serious Incident reports and corresponding action plans are presented at the Chief Executives Advisory Group (CEAG) for Chief Executive approval.

6.6. The Clinical Governance and Patient Safety team will submit the final report

to STEIS (national Strategic Executive Information System) for L1 and L2 SIs.

6.7. The Governance Facilitation Team will add actions from all RCAs to Datix and monitor implementation. Status of implementation with actions will be reported to the specialties and divisional management teams who are responsible for ensuring that actions are implemented in a timely manner.

6.8. The Trust Clinical Quality Monitoring Group (CQMG) will receive updates on

the status of implementation of action plans following level 1 and 2 investigations.

7. Reporting to external agencies

7.1. External reporting of incidents provides assurance to external stakeholder that the Trust has responded to the investigation’s findings and learning is achieved to reduce the risk of recurrence in the wider health care economy.

7.2. All patient clinical incidents are reported to the National Reporting Learning

System (NRLS) by the Datix Manager.

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7.3. All clinical incidents triggering a level 1 or 2 SI investigation are reported on STEIS within 2 working days of an SI being commissioned. This automatically informs the CCG of the incident.

7.4. If in the course of an investigation an issue is identified which meets

Coroner’s referral criteria, the case is referred to the Medical Director for notification.

7.5. The Coroner is provided with a copy of the Investigation report where an inquest is being held or is being considered. If an inquest is held, the clinical support for the investigation will be called as a witness by the Coroner.

7.6. Incidents involving Sudden Unexpected Death in Infants and Children (SUDIC) incidents must follow the Process for the death of all under 18 years old (SUDIC) as well as this procedure.

7.7. Incidents within the NHS Cancer Screening Programme (NHSCSP) should be managed in line with current screening programme guidelines and timeframes and should reference the current guidance which can be found at http://www.screening.nhs.uk/incidents.

7.8. Other external agencies reporting requirements are detailed in Appendix F.

8. Incidents raised through other processes

8.1. Medical Examiners (ME) review all deaths at the Trust which have not been referred to the coroner. The Clinical Governance and Patient Safety department initiates further follow-up of any cases that are escalated by MEs following scrutiny review.

8.2. Following review of mortality alerts, the Clinical Governance and Patient Safety team will identify any unexpected deaths which will be reported on Datix and investigated further.

8.3. The Clinical Governance and Patient Safety team will work closely with Patients services and Legal teams to ensure that, where appropriate, any concerns are reported on Datix and investigated further. Details of how the departments work together are detailed in Appendix B and C.

9. Incidents raised by other organisations

9.1. There will be occasions where other organisations wish to raise safety concerns with the Trust.

http://www.screening.nhs.uk/incidents

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9.2. Incidents should be reported to the Trust’s Clinical Governance and Patient Safety Team via [email protected] who will:

9.2.1. Record the incident on the Trust’s Datix system;

9.2.2. allocate the appropriate handler to investigate the incident;

9.2.3. share the findings from the investigation with the organisation who has raised the incident.

9.3. Incidents raised via the Midlands Trauma Network will be reviewed and managed in line with the Trust’s Policy & Procedure for the reporting and management of incidents including serious incidents. The reporting framework for the management of trauma related issues is detailed in Appendix G.

10. Producing reports

10.1. Divisional and specialty reports

10.1.1. Clinical Governance and Patient Safety will produce monthly and quarterly reports to Division and Specialty which will detail:

a) incident trends, b) status of Divisional, Exec RCA, Level 1and 2 investigation c) status of implementation of actions following completion of the above

investigations

10.1.2. A weekly report is generated by Informatics identifying all handlers with overdue incidents. This is shared with the Division management teams.

10.1.3. The Clinical Governance & Patient Safety Team will also produce a

number of other reports for specialist teams within the Trust.

10.2. Aggregated report

10.2.1. The purpose of analysing aggregated data is to assist the Trust in learning from incident data, complaints and claims. The raw data regarding incidents, complaints, and claims is collected and collated in Datix.

10.2.2. The raw data is aggregated into specific themes and a written report is produced by the Head of Clinical Governance and Patient Safety, the Head of Patient Relations and the Head of Legal Services on a

mailto:[email protected]

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quarterly basis containing both quantitative analysis, depicted in table and graph format along with narrative qualitative analysis.

10.2.3. The aggregated report is presented to CQMG and the Board of Directors on a quarterly basis.

11. Learning from Incidents

11.1. Learning from incidents is a key requirement of the incident reporting and management process. Learning and change arising from incidents, aggregate review and wider experiences, is key to improving the quality of care provided to patients, the safety of staff and members of the public.

11.2. Learning from incidents is facilitated by:

11.2.1. Monitoring the implementation of actions identified following Level 2 investigations;

11.2.2. Reporting of trends from incidents to Divisions, Specialties and Specific Leads;

11.2.3. A quarterly summary of incidents, Serious Incidents, harm rated and compliance with risk management processes provided to the Divisional and Specialties management teams.

11.2.4. Executive RCA meetings. Cases for discussion at Executive RCA will be selected at CaPRI by the Chair.

11.2.5. Aggregated reports presented to the CQMG, Board of Directors and detailing incidents, complaints, claims and PALS data;

11.2.6. The National Reporting and Learning System (NRLS) feedback reports received on a bi-annual basis providing comparative data against the cluster;

11.2.7. Learning shared outside the organisation on a quarterly basis to the CCG via the aggregated report.

12. Identifying risks

12.1. If a risk is identified as a result of an incident, consideration must be given to adding this to the relevant risk register for monitoring and to ensure measures are in place to reduce the risk.

12.2. Information on how to identify, record and manage risks is provided in the Risk management Policy & Procedure.

13. Training

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13.1. The Clinical Governance and Patient Safety Team provides training on all aspects of the incident reporting, management and the investigation process as required. Please refer to training course available on the Trust intranet site.

14. Supporting staff involved in an incident

14.1. The Trust recognises that it has a responsibility to all staff to support them following an incident. The Trust discourages blame of staff when they are involved in an incident, however this does not relieve staff of their professional accountability.

14.2. Staff members who have been affected by an incident may require exclusion from duty pending further investigation. Any suspension or exclusion from duty must be in line with the appropriate Human Resources policy and procedure.

14.3. It is the Incident Handler’s responsibility to ensure support for staff involved in an incident is made available. The Handler can do one or more of the following:

14.3.1. Provide the staff member with a list of support agencies available to staff within the organisation (Appendix H);

14.3.2. Obtain staff support leaflets from Occupational Health;

14.3.3. Offer one-to-one counselling and long-term support via the Staff Support Service. This service is independent from the management structure and is completely confidential;

14.3.4. Obtain advice from Occupational Health or senior management if there are any further concerns.

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15. Associated documents

15.1. Policy for the Reporting and Management of Incidents Including Serious Incidents

15.2. Duty of Candour (Being Open) Policy & Procedure

15.3. Level 1 Serious Incident SOP

15.4. Claims Handling Policy & Procedure

15.5. Patient Relations Policy & Procedure

15.6. Reviewing Inpatient Death Policy & Procedure

15.7. Inoculation Injury Management Including Sharps and Splashes with Body Fluids Procedure

15.8. Information Security and Access Policy

15.9. Manual Handling Procedure

15.10. Medical Devices Policy and Procedure

15.11. Procedure for the Prevention, Reduction and Management of Slips, Trips and Falls Including Work at Height

15.12. Policy and Procedure for Raising Concerns in the Public Interest (Whistle blowing)

15.13. Procedure for the Reporting and Management of Incidents including Serious Incidents

15.14. Radiation Safety Policy

15.15. Security Policy and Procedures

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Appendix A: Definitions

Incident An unplanned or unexpected event that may or may not lead to injury, damage or loss to an individual or the Trust.

Near Miss An unplanned or unexpected event that had the potential to lead to injury, damage or loss to an individual or the Trust, but was prevented.

Assault The intentional application of force against the person of another without lawful justification, resulting in physical injury or personal discomfort

Verbal aggression The use of inappropriate words or behaviour causing distress and/or constituting harassment

Hazard Any thing or process that could cause injury, harm or loss to patients, staff, visitors, or the structure/financial integrity of the organisation.

Patient Safety Incident Any unintended or unexpected incident(s) that could have or did lead to harm for one or more persons receiving NHS-funded healthcare.

Harm Harm is defined using the NRLS definitions as per Appendix D

Serious Incident In broad terms, serious incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.

There is no definitive list of events/incidents that constitute a serious incident. See the SI Framework for more information and definitions.

Incident Handler The individual who is responsible for ensuring the appropriate management and investigation of an incident in line with this policy.

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Appendix B: NRLS definition of level of harm

• Low

Any unexpected or unintended incident that required extra observation or minor treatment and caused minimal harm to one or more persons.

Examples Perforation of the bowel during surgery,that was repaired at the time and the area was appropriately washed out. Only antibiotic treatment is required. A patient is given someone else's medication. The medication is the same as they normally take, but at a slightly higher dose, and they need to go to bed earlier due to drowsiness. Continuing treatment with warfarin without monitoring clotting levels, which results in prolonged clotting times, and in turn causes bruising. An ambulance crew are called to a patient at home with chest pain. On arrival they decide to administer oxygen, and are then told the patient has had a laryngectomy. There are no laryngectomy masks on the vehicle so the crew have to attempt to oxygenate the patient using a face mask over the stoma. On arrival in A&E the patient's oxygen saturation levels have dropped from 92% to 85%. Blood is given to the wrong patient and causes a minor rash and temporary rise in temperature.

• Moderate

Any unexpected or unintended incident that resulted in further treatment, possible surgical intervention, cancelling of treatment, or transfer to another area, and which caused short-term harm to one or more persons.

Examples Perforation of the bowel during surgery was not picked up at the time. It results in septicaemia and a return to theatre for repair. A patient is given someone else's medication. The medication is stronger than their own and they suffer prolonged drowsiness for a week. The patient needs frequent observation of their respiratory rate. Continuing treatment with warfarin without monitoring clotting levels, which results in an overdose and bleeding problems. An ambulance crew are conveying a patient from the ambulance to A&E on a trolley bed. The patient is left unattended for a short period and the trolley bed tips over. The patient suffers short-term loss of consciousness and needs to be admitted to hospital for observation. There is no longer-term head injury. Wrong blood is given to a patient, resulting in temporary renal failure.

• Severe

Any unexpected or unintended incident that caused permanent or long-term harm to one or more persons.

Examples Perforation of the bowel during surgery, requiring a temporary colostomy and subsequent major operations. A patient is given someone else's medication. They have an allergic reaction to it, have a cardiac arrest and suffer brain damage as a result of receiving the medication.

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Continuing treatment with warfarin without monitoring clotting levels, which results in a brain haemorrhage and brain damage. An ambulance is called to a patient who has fallen from scaffolding. On arrival the patient is conscious but lying awkwardly, with a leg that is clearly fractured and twisted. Before carrying out a full assessment or immobilising the cervical spine, the crew reposition the patient to straighten the leg. After repositioning, the patient is unable to move any of their limbs, and later investigations identify that they have a cervical fracture and spinal cord damage. The spinal cord was, however, immobilised immediately after repositioning. The patient is left with long-term paralysis from the neck down. Wrong blood is given to a young woman, who then develops anti-D antibodies that will affect any future pregnancy.

• Death

Any unexpected or unintended event that caused the death of one or more persons.

Examples Death as a direct consequence of perforation of the bowel during surgery. A patient is given someone else's medication. They have an allergic reaction to it, have a cardiac arrest and die as a result of receiving the medication. Continuing treatment with warfarin without monitoring clotting levels, which results in a brain haemorrhage and death. An ambulance responding to an emergency call on blue lights goes through red traffic lights at an intersection. A car approaching the intersection has a green light, does not see the ambulance and attempts to cross. The ambulance is unable to stop and hits the car on the driver's side. The driver of the car suffers multiple injuries and later dies in hospital. Wrong blood is given to a patient resulting in multi-organ failure and death.

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Appendix C Working with complaints and concerns process

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Appendix D: Working with Legal Services Process

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Appendix E: Incident investigation process with timeframes The tables below provide an overview of what is required when carrying out investigations: Divisional and Exec RCAs

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Level 1 Investigations Action Responsible for

completing Date of completion

Create initial timeline of events Falls/IPC/tissue viability specialist team/Division

Working to timeframe given in L1 SI SOP

Identify who needs to give a statement based on the timeline and initial information

Specialist team/Division

Interviews and/or roundtable held as relevant.

Specialist team/Division

Draft investigation report using specialist review templates

Ward team/Specialist team

Draft report reviewed by Clinical Governance and Patient Safety and specialist team

Clinical Governance and Patient Safety /specialist team

Draft report reviewed by Chief Nurse and Medical Director and Deputy

Chief Nurse, Medical Director, deputy Medical Director

Final report and action plan completed by Divisional Management Team for presentation at CEAG or Exec RCA.

Divisional Management Team

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Level 2 Investigations: Serious Incidents & Internal Serious Incidents Action Responsible for

completing Date of completion

Locate notes and photocopy as required Investigation Officer / Risk & Compliance with help from Division

Day 14

Create initial timeline of events

Identify who needs to give a statement Investigation Officer with help from Division

All statements and any interviews required completed

Investigation Officer with help from Division

Day 28

Draft investigation report Investigation Officer Day 40 IQAM Investigation Officer Report submitted to CaPRI for approval Investigation Officer Draft report reviewed by Chief Nurse and Medical Director/Deputy Medical Director

Chief Nurse and Medical Director/s

Day 60

Final report and action plan completed by Divisional Management Team for presentation at CEAG.

Divisional Management Team

Draft action plan reviewed by Clinical Governance and Patient Safety and submitted to the CCG with the report*.

Clinical Governance and Patient Safety/ Investigation Officer

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Appendix F – Reporting to external Agencies

Organisation/Process

UHB Lead

Requirements for reporting Timescales Method

CQC - Mental Health Notifications

Becky Hoskins Clinical Compliance/Educator for Mental Health

1. Death of a detained patient 2. Child or young person placed

on an adult ward for longer than 48 hours

As soon as possible

1. Either by UHB mental health lead or UHB CQC lead via CQC provider portal or by completion of form http://www.cqc.org.uk/sites/default/files/20161212-800139v5_notification-death-patient-liable-to-be-detained.doc form to be emailed to [email protected]

2. Either by UHB mental health lead or UHB CQC lead via CQC provider portal or by completion of form http://www.cqc.org.uk/sites/default/files/documents/20110614_awol_notification_updated_add_0.doc form to be emailed VIA NHS.NET ONLY by arrangement with the Mental Health Operations Team by calling 03000 616161 (press option 1 when prompted). Or sent by secure fax on: 03000 200238

3. Either by UHB mental health lead or UHB CQC lead via CQC provider portal or by completion of form http://www.cqc.org.uk/sites/default/files/documents/20130611_800142_v2_00_paper_notification_child_on_adult_psychiatric_ward_for_publication.doc to be sent to [email protected]

Further information: CQC Mental Health Notifications (2017) http://www.cqc.org.uk/guidance-providers/registration-notifications/mental-health-notifications Fraud Lorna

Barry Local Counter Fraud Specialist Mike Sexton

Suspected patient fraud, such as wrongful claiming of exemption fees, identity fraud to obtain prescription drugs. Suspected professional fraud, such as undertaking private work in NHS time.

No designated times frames, dependent on case by case basis.

Suspected fraud should be reported to the Local Counter Fraud Specialist: Tel: 0121 695 5539 Email: [email protected] The details of the referral will be shared with Chief Financial Officer, Director of Corporate and Director of Human Resources. Chief Finance Officer will commission investigation which will be

http://www.cqc.org.uk/sites/default/files/20161212-800139v5_notification-death-patient-liable-to-be-detained.doc

http://www.cqc.org.uk/sites/default/files/20161212-800139v5_notification-death-patient-liable-to-be-detained.doc


http://www.cqc.org.uk/sites/default/files/documents/20110614_awol_notification_updated_add_0.doc

http://www.cqc.org.uk/sites/default/files/documents/20110614_awol_notification_updated_add_0.doc

http://www.cqc.org.uk/sites/default/files/documents/20130611_800142_v2_00_paper_notification_child_on_adult_psychiatric_ward_for_publication.doc




http://www.cqc.org.uk/guidance-providers/registration-notifications/mental-health-notifications


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Chief Financial Officer

Suspected managerial/staff fraud such as inflated timesheets/expenses, falsified HR documents. Suspected contractor/supplier fraud, such as price fixing, inappropriate tendering process.

undertaken by Local Counter Fraud Specialist in conjunction with relevant authorities as required.

Further information: http://www.uhb.nhs.uk/Downloads/pdf/controlled-documents/CounterFraudCorruptionPolicy.pdf (2017) http://www.ncuh.nhs.uk/about-us/how-we-govern/accounts/fraud-booklet.pdf Health & Safety Executive (HSE) - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR)

Adam Aucutt Health & Safety Manager

1. Deaths 2. Specified injuries including:

- • fractures, other than to

fingers, thumbs and toes • amputations • any injury likely to lead to

permanent loss of sight or reduction in sight

• any crush injury to the head or torso causing damage to the brain or internal organs

• serious burns (including scalding) which: covers more than 10% of the body

• causes significant damage to the eyes, respiratory system or other vital organs

• any scalping • any loss of consciousness

1. Same day

2. Ten days 3. Fifteen

days 4. “Without

delay” (no more than ten days)

5. Ten days

1. Health And Safety Team contact the HSE by phone (0345 300 9923)

2. Health And Safety Team complete a an online RIDDOR Report

http://www.uhb.nhs.uk/Downloads/pdf/controlled-documents/CounterFraudCorruptionPolicy.pdf

http://www.ncuh.nhs.uk/about-us/how-we-govern/accounts/fraud-booklet.pdf

http://www.hse.gov.uk/riddor/report.htm

http://www.hse.gov.uk/riddor/report.htm

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caused by head injury or asphyxia

• any other injury arising from working in an enclosed space which: leads to hypothermia or heat-induced illness

• requires resuscitation or admittance to hospital for more than 24 hours

3. Over-seven-day incapacitation

4. Occupational diseases 5. Dangerous occurrences

Further information: RIDDOR - Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (2013) http://www.hse.gov.uk/riddor/ Human Tissue Authority (HTA)

HTA Lead for Human Application Licence (Julie Dulson)

1. Serious Adverse Events and Serious Adverse Reactions (SAEARs): Serious Adverse Event (SAE) Means any untoward occurrence associated with the procurement, testing, processing, storage and distribution of tissues and cells that might lead to the transmission of a communicable disease, to death or life-threatening, disabling or

SAEARs must be notified to the HTA within 24 hours of discovery that occurs at QEHB,

Reported by Designated Individual (DI) or Persons Designated (PDs) via the HTA web Portal, by clicking the ‘HTA Reportable Incident tab.https://portal.hta.gov.uk/user/login?destination=node/109 A HTA Regulation Manager will be assigned to review the incident. A follow up report is submitted by the DI to the HTA within 90 days of reporting the SAEARs, including the results of an internal investigation and the corrective and preventative actions

http://www.hse.gov.uk/riddor/

https://portal.hta.gov.uk/user/login?destination=node/109

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DI for Post Mortem (Dr Rachel Brown)

incapacitating conditions for patients or which might result in, or prolong, hospitalisation or morbidity. Any SAE that may influence the quality and/or safety of tissues and/or cells. Serious Adverse Reaction (SAR) Means an unintended response, including a communicable disease in the donor or in the recipient associated with the procurement or human application of tissues and cells that is fatal, life threatening, disabling, incapacitating or which results in, or prolongs, hospitalisation or morbidity. Any SAR observed during and after clinical application which may be linked to the quality and/or safety of tissues. 2.Post mortem reportable

End user establishments or third parties. Report on DATIX Notify the Divisional Management Team. Incident to be investigated and managed by the relevant speciality team/PD(s).

taken. A Regulation Manager from HTA will be assigned to the incident. The DI must submit a report to HTA within 2 months on behalf of the Trust.

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incidents, examples include: Accidental damage to body Wrong body released/PM performed/viewed Loss, disposal or retention of tissue/organ

HTARIs to be reported within 5 working days, 2 months for investigation.

Further information: Human Tissue Authority (2016) https://www.hta.gov.uk/ https://www.hta.gov.uk/policies/human-application-adverse-event-and-reaction-saears-reporting https://www.hta.gov.uk/faqs/faqs-serious-adverse-events-and-serious-adverse-reactions https://www.hta.gov.uk/sites/default/files/Reporting_SAEARs.pdf https://www.hta.gov.uk/policies/post-mortem-hta-reportable-incidents Infection Prevention

Mark Garvey

Day that infection contracted determines lead organisation for

Reporting deadlines to CCG vary dependent on infection

IPC team to confirm requirement to report following incident report.

https://www.hta.gov.uk/policies/human-application-adverse-event-and-reaction-saears-reporting

https://www.hta.gov.uk/faqs/faqs-serious-adverse-events-and-serious-adverse-reactions

https://www.hta.gov.uk/sites/default/files/Reporting_SAEARs.pdf

https://www.hta.gov.uk/policies/post-mortem-hta-reportable-incidents

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& Control Lead Scientist Infection Prevention and Control

Post Infection Review (PIR) process: Day 1-2: Clinical Commissioning Group (CCG) Day 3: Trust

and number of patients affected:

• MRSA Bacteraemia – 15 working days

• Period of Increased Incidence – 30 working days

• Death following C Difficile infection – 30 working days

• Contraction of an infection e.g. Hepatitis C, TB – 60 working days

Further information: Post Infection Review Process, NHS Improvement (2014) https://improvement.nhs.uk/uploads/documents/post-infection-guidance.pdf Information Governance

Berit Reglar Deputy Foundation Secretary

Serious Incident (SI) overseen by Information Commissioner’s Office (ICO). Level of investigation determined through ICO SI matrix. Level 1: internal, local handling via Datix

To be reported as soon as practicable with as much information as possible. A full record should be completed within 5

Information Governance to report via IG Incident Reporting Tool and STEIS.

https://improvement.nhs.uk/uploads/documents/post-infection-guidance.pdf

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Level 2: externally reportable to ICO

working days.

Further information: Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents Requiring Investigation (IG SIRI), Health and Social Care Information Centre (HSCIC) (2014) https://www.igt.hscic.gov.uk/resources/IGIncidentsChecklistGuidance.pdf https://www.igt.hscic.gov.uk/resources/The%20Incident%20Reporting%20Tool%20User%20Guide.pdf https://www.igt.hscic.gov.uk/help.aspx? Ionising Radiation (Medical Exposure) Regulations (IRMER)

Imaging –Deputy Director of Operations, Division A Radiotherapy – Consultant Clinical Scientist Graham Chalmers, Head of Radiotherapy Physics

Incident meeting criteria to be reported to CQC, who will triage process and investigate as required. CQC may visit if deemed necessary. Incident will be formally closed by CQC via letter.

To be reported as soon as practicable after exposure confirmed or at least within two weeks. No specified deadlines for investigation process.

UHB lead to report to CQC via http://www.cqc.org.uk/guidance-providers/ionising-radiation/reporting-irmer-incidents

Further information: Reporting IRMER incidents, CQC (2017) http://www.cqc.org.uk/guidance-providers/ionising-radiation/reporting-irmer-incidents http://uhbpolicies/assets/IrmerProcedure11.pdf Medicines and Healthcare products

Medicines - Inderjit Singh Chief Pharmacist

Suspected problems with medicines and medical devices should be reported to the MHRA via the Yellow Card

To be reported as soon as practicable. No specified

Medicines - Yellow card lead to report via portal. Incidents monitored by Chief Pharmacist. Medical Devices – Users (reporters and/or handlers)

https://www.igt.hscic.gov.uk/resources/IGIncidentsChecklistGuidance.pdf

https://www.igt.hscic.gov.uk/resources/The%20Incident%20Reporting%20Tool%20User%20Guide.pdf

https://www.igt.hscic.gov.uk/help.aspx

http://www.cqc.org.uk/guidance-providers/ionising-radiation/reporting-irmer-incidents



http://uhbpolicies/assets/IrmerProcedure11.pdf

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Regulatory Agency (MHRA)

Medical Devices - Medical Engineering Manager Mandy Hill

Scheme. Incident examples include:

• Medicine is of poor quality, counterfeit, causes side effects

• Someone is harmed or nearly harmed by a medical device due to user error, malfunction

Incident is triaged by MHRA and investigated depending on severity of incident.

deadlines for investigation.

provide report to Medical Engineering Manager, who also monitors incidents.

Further information: MHRA Yellow Card Scheme (2017) https://www.gov.uk/report-problem-medicine-medical-device Maintaining High Professional Standards (MHPS)

Medical Director Human Resources

Concerns or allegations surrounding a practitioners conduct or capability, as defined in the Maintaining High Professional Standards Policy.

Concerns to be raised as soon as possible. 12 week target for investigation process.

Concerns raised to HR/Medical Director, who appoints a case manager to oversee the investigation. Exclusion and alternatives to exclusion to be considered. The Case Manager and Investigating Team investigate the concerns. This can progress to a formal hearing with a Conduct or Capability Panel where a decision is made on actions.

Further information: Maintaining High Professional Standards Policy and Procedure (2017) http://uhbpolicies/maintaining-high-professional-standards.htm National Reporting and Learning System (NRLS)

Clinical Governance and Patient Safety

Incidents where it has either caused harm to a patient or potential to cause harm to a patient. A patient safety incident (PSI) is defined as: Any unintended

Regularly; NRLS recommend weekly reporting for large Trusts.

Incidents are reported via https://report.nrls.nhs.uk/nrlsreporting/ Datix Manager uploads incident extract to NRLS site. Only registered users whose role is enabled for Upload Patient Safety Incidents can do this.

https://www.gov.uk/report-problem-medicine-medical-device

http://uhbpolicies/maintaining-high-professional-standards.htm

https://report.nrls.nhs.uk/nrlsreporting/

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or unexpected incident(s) that could have or did lead to harm for one or more person(s) receiving NHS funded healthcare. Data Quality Standards (2009) Incidents where staff, visitors or other people have been harmed should not be reported to the NRLS.

Incidents which are SI’s must be reported within two working days of the incident occurring (as per STEIS).

Further information: National Reporting and Learning System (NRLS) & NHS Improvement (2016) https://report.nrls.nhs.uk/nrlsreporting/ http://www.nrls.nhs.uk/patient-safety-data/ https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-data/ NHS Blood & Transplant: Organ Donation

Managed per specialty

Serious Adverse Events (SAE) and Serious Adverse Reactions (SAR) to be reported to NHS Blood and Transplant as per protocol. Incident to be investigated by Organ Donation and Transplant (ODT).

To be reported within 24 hours of discovery Incident investigation to be closed within 90 days

UHB specialty lead to submit incident via https://safe.nhsbt.nhs.uk/IncidentSubmission/Pages/IncidentSubmissionForm.aspx

Further information: STANDARD OPERATING PROCEDURE SOP3888/2.2 Reporting an Organ Donation or Transplantation Incident to NHSBT, Human Tissue Authority (2017) https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/6032/sop3888-reporting-an-organ-donation-or-transplantation-incident-to-nhsbt.pdf NHS Screening

Managed per Specialty,

The programmes covered by the guidance:

• Breast screening

Screening Incident Assessment form (SIAF) to be

Screening lead to liaise with regional Screening Quality Assurance Service (SQAS) to confirm if SIAF required

https://report.nrls.nhs.uk/nrlsreporting/

http://www.nrls.nhs.uk/patient-safety-data/

https://improvement.nhs.uk/resources/organisation-patient-safety-incident-reports-data/

https://safe.nhsbt.nhs.uk/IncidentSubmission/Pages/IncidentSubmissionForm.aspx

https://safe.nhsbt.nhs.uk/IncidentSubmission/Pages/IncidentSubmissionForm.aspx

https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/6032/sop3888-reporting-an-organ-donation-or-transplantation-incident-to-nhsbt.pdf

https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/6032/sop3888-reporting-an-organ-donation-or-transplantation-incident-to-nhsbt.pdf

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• Cervical screening • Bowel cancer

screening • Diabetic eye screening • Abdominal Aortic

Aneurysm (AAA) Screening

• Foetal anomaly screening

• Infectious diseases in pregnancy

• Sickle cell and thalassaemia

• Newborn blood spot • Newborn hearing

screening • Newborn and infant

physical examination

completed as per process within 5 working days of incident occurring. Local investigation, safety incident or serious incident declared as appropriate. Report to be completed within 60 working days unless otherwise agreed.

and liaise with the Clinical Governance and Patient Safety Team.

Further information: Local SQAS contact information: [email protected] 0333 014 2478 Managing Safety Incidents in NHS Screening Programmes, Public Health England (2017) https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes R & D Joanna

Gray Clinical Manager NIHR Clinical Research

Incidents are defined in conjunction with the specific study plan e.g. side effects not stated as expected would constitute as an incident. Three tiers of incidents:

• Adverse Event (AE)

To be reported as soon as practicable. No specified deadlines for investigation.

Incidents are reported to the trial sponsor who conduct and investigation and report to MHRA.


https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes

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Facility • Serious Adverse Event (SAE)

• Suspected Unexpected Serious Adverse Reaction (SUSAR)

Further information: Safety reporting, NHS Health Research Authority (2018) https://www.hra.nhs.uk/approvals-amendments/managing-your-approval/safety-reporting/ Safeguarding

Lead Nurse Safeguarding

Procedure for cases in which there is an allegation or suspicion that a person is exploiting, abusing or otherwise harming a person with care needs, child or young person.

To be reported as soon as possible. Process and timescales vary dependent on type of investigation

When alleged abuse is identified: • Report as an incident • Complete a multi-agency alert form and email to

Community Care team and Safeguarding team Staff can contact Safeguarding team for advice/urgent concerns on 07500850633 Relevant agency will investigate concerns, process and timescales vary dependent on severity.

Further information: https://www.bsab.org/publications/policy-procedures-and-guidance/ http://www.lscbbirmingham.org.uk/ Strategic Executive Information System (STEIS)

Clinical Governance & Patient Safety Team

Serious Incidents (SIs) in line with the Serious Incidents Framework Never Events Contractually agreed SIs: Falls with harm, Grade 3 and 4 hospital acquired pressure ulcers, reportable infections

Report within 2 working days of confirmation of Serious Incident For Never Events, a 72 Hour Update must be provided within 3 working days of initial reporting of SI to

Clinical Governance and Patient Safety will report the incident to STEIS via http://nww.steis.doh.nhs.uk/steis/steis.nsf/main?readForm 72 hour update will be provided by Investigations team via NHS.net account to [email protected]

https://www.hra.nhs.uk/approvals-amendments/managing-your-approval/safety-reporting/

https://www.bsab.org/publications/policy-procedures-and-guidance/

http://www.lscbbirmingham.org.uk/

http://nww.steis.doh.nhs.uk/steis/steis.nsf/main?readForm


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STEIS Further information: Serious Incidents Framework, NHS England (2015) https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf

https://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf

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Appendix G Trauma Related Issues Database (TRID) Reporting Framework

Initial Documentation Process • The Network Governance Lead will enter details into the database and record how

the TRID will be investigated, either: o Internal only o Network Board o Performance & Quality Group (PaQ) o Oversight Board

• The Network Governance Lead will initiate the investigation process if not already done so by the person reporting the TRID.

Organisations will submit TRID’s to Network Governance Lead at the Network Office as early as possible via secure email to [email protected] or website https://www.mcctn.org.uk/trid.html

Internal Only • TRID’s to be discussed on a

one to one basis between the reporting organisation and a

representative of the organisation the issue is

regarding.

• TRID’s can also be discussed at Trust governance/M&M

meetings in accordance with Trauma Governance Strategy

& local policies

Network Governance Meetings Involving:

• In depth case study presentations/review

• Identifying themes/learning points/service improvement

• Identifying actions and recording outcomes

• Identify if requires escalation to PaQ or Oversight Board

Investigation Process

PAQ Meeting

Involving: • Analysis of high

risk/severe/regularly occurring TRID’s

• Identifying actions and reporting outcomes

• Identify learning points/service improvement

• Develop escalation plan for issues escalating to the oversight Board (where necessary)

Trauma Oversight Board

TRID’s presented with evidence of the

investigation and the reasons for escalation.

The Board will decide on the agreed course of

action(s) and will receive progress reports until all agree that the TRID can

be closed.

Keeping the Database up to date It is imperative that we aim for ‘timely governance’. You will be required to: (i) Respond within 14 days of initial notification of the TRID. (ii) Investigate the TRID within 8 weeks of receiving the notification. When

you are unable to meet the deadlines, notify the Network Governance Lead. • Automatic reminders will be sent to you and recorded on the database when

you fail to respond to the Governance Lead. • During the investigation process the Network Governance Lead will record the

feedback/actions/outcomes on the database. This will continue until everyone involved is in agreement that the TRID can be closed.

• The closure date is recorded and the details of the TRID are sent via a closing letter to all involved in the investigation.

TRID Received in Organisation • When received, the Organisation Governance Lead will report the TRID via incident

reporting system and follow procedure for escalation as appropriate. • If further investigation required at organisational level, TRID will be paused pending

investigation feedback.


https://www.mcctn.org.uk/trid.html

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Appendix H: List of services available to provide staff support Chaplaincy The Trust Chaplaincy is available to provide confidential spiritual and personal support to all staff from all backgrounds and faiths. Patient Services Department The Patient Services Department can advise staff and give preparatory support in respect of writing written statements in response to complaints from patients or their representatives. Staff Support The Staff Support Service is free for Trust employees and is accessible through Occupational Health or via self-referral. They aim to create a safe and neutral environment for staff to access and make use of confidential counselling. Human Resources Largely confined to non-patient related issues, the Human Resources (HR) Department will provide preparatory and ongoing support and advice to staff acting as witnesses at disciplinary, grievance and employment tribunal hearings. This will extend to senior staff that may be required to undertake the role of Investigating Officer, hearing panel member or the officer presenting a case. Head of Legal Services (including advice for staff being called as a witness) The Head of Legal Services is available to provide support and advice to staff in the event of their being called as a witness. The support and advice will include:

• An explanation of the relevant process, including how long the process could take

• Accompanying the member of staff to court, during inquests or at formal interviews with solicitors

• An ongoing dialogue during the whole process

• Maintaining documentation of all of the above support offered to staff.

The legal services team can also advise individuals with regard to clinical negligence claims, personal injury claims against the Trust, inquests and ad-hoc legal matters. Note: In the event a staff member is claiming against the Trust, the legal services team is prohibited from providing advice to staff. Occupational Health The Occupational Health Department is able to advise on coping strategies for staff experiencing signs of anxiety or stress as a direct consequence of the incident in question. Occupational Health involvement may be appropriate when staff are

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involved in particularly stressful or traumatic clinical incidents such as complaints, a major road traffic accident, violent patient incident or a court appearance as a Trust representative. This interaction will be on a confidential basis and may include referral to Clinical Psychology Service, the employee’s General Practitioner (GP) or other appropriate agencies. Clinical Governance and Patient Safety The Clinical Governance and Patient Safety Team can advise staff and give preparatory support in respect of implementing the various risk management processes, such as reporting of incidents, carrying out an internal investigation and updating risk registers. Security The Trust’s Security Advisors can provide support and advice on task redesign and repeat risk avoidance in relation to violent incidents at work, and will refer to the NHS Security Management Service where necessary. Staff Side/Trade Union Representative Working closely with HR and line management, trade union representatives will be able to provide an insight into the processes associated with internal performance management issues such as disciplinary, grievance and appeal hearings. Trade Union representatives will also be able to guide the member toward union legal advice and assistance should this be necessary.

Documents

Incident - UHB · 4.2.2. The Clinical Governance and Patient Safety quality team will assure the Datix incident form liaising with relevant staff where necessary, and establish whether