Significant Event and Escalation Procedure

Version Date Ratified at Board Review Date1 Angela Shaw Head of Operations and Governance

November 2019 December 2020

1

SIGNIFICANT EVENT AND ESCALATION PROCEDURE

1. Introduction

Connect Healthcare Rotherham CIC is committed to:

Fostering an open and fair culture committed to learning

Ensuring that lessons are learned as part of the organisations commitment to maintaining high quality services and supporting staff

Formalising roles and responsibilities to ensure that critical events are managed effectively and appropriately

Ensuring the provision of feedback to all staff

2. Objectives of significant/critical event reporting

o To record adverse incidents effecting, or with the potential to effect patients or staffo To record “near misses” so that steps may be taken to prevent a recurrenceo To learn from the event as a team, discuss, and put change or procedures in place to

improveo To commend and acknowledge good practiceo To provide a permanent record of events and evidence of remedial steps takeno To satisfy the requirements of QOF and nationally required incident reporting

standardso To operate and discuss incidents in an open environment and within the safety of a

learning culture

3. Incident Reporting & Management

Connect Healthcare recognises its responsibility to report, record, investigate and learn from all incidents. Research has shown that the more incidents are reported, the more information is available about what is going wrong, and the more action can be taken to improve safety in healthcare

It is the responsibility of all staff (including doctors, clinical and administrative staff, both temporary and permanent) to report significant/critical events. A Significant Event Record form is at Appendix 1

2

When an incident has occurred, the first priority of staff must be to minimise harm, attend to immediate health needs and ensure the area is safe

All incidents and near miss incidents including those involving safeguarding and Deprivation of Liberty (DoLs) must be reported as soon as practicably possible following the event

It is important that any incident suspected as a Serious Incident is notified to the senior management at Connect Healthcare within 2 working days. The notification ensures communication of incidents

All incidents that may meet the Serious Incident classification must be escalated to a senior member Connect Healthcare Staff. The decision as to whether an incident should be declared as a Serious Incident lies with the Medical Director following discussion with the CCG

Every person with a significant part in, or witnessing an incident, should each complete a Significant Event Report Form independently and without conferring as soon as possible after the incident. This will ensure that each account of the proceedings is, as far as possible, as accurate as it can be and without the influence of a third party. Each statement will form part of the incident record. Event record forms are disclosable if legal proceedings follow and should not be stored or recorded in the patient’s record.

Incidents should be investigated within 30 working days of the incident being reported. There will be exceptions to this such as Serious Incidents that require a longer time to investigate.

4. Notes on completing report forms

4.1. Each person involved in, or witness to, the event will complete a Report Form to record:

Date / time The time of the incident may be a critical part of the record (e.g. in the case of a communication failure).

Brief description This is the witness or staff statement of the events from their own perspective. This may disagree or conflict with other accounts of the event, and this is in order. No attempt should be made to influence a

3

change to the statement although a written note of any points clarified may be made.

4.2. Completed forms should be passed to the nominated person Serena Thorpe, Lead

Development Nurse for Connect Healthcare Rotherham CIC, to collate for an initial check. Forms should be emailed to connecthealthcare.rotherham@nhs.net with the title ‘Incident Report’ and marked as urgent. The Lead Development Nurse will ensure that the forms are properly completed and any queries arising from each account of the incident can be raised in good time. The nominated person can also assess at this point whether any urgent or remedial action is required without delay (e.g. for health and safety issues) and initiate this.

4.3. A review of the event should be carried out as soon as possible after the event, once all the report forms have been gathered by the nominated person. A Significant Event Review form should be used to record the outcomes of the review session. A draft Significant Event Review form is at Appendix 2.

4.4. Where, during the course of the investigation or discussion of a Significant Event, it becomes apparent that further open discussion is not appropriate to the circumstances surrounding the incident, the matter will be reserved for individual action and investigation. It is envisaged that this will apply in exceptional circumstances only.

4.5. When identified as a significant event or near miss incident a full incident investigation report will be completed by a nominated senior member of staff .

5. Event Review

5.1. At the event review meeting the following will be discussed:

Key risk issues The main elements of the incident will be identified - this will assist in the formulation of specific action points to address each of the risk areas (including actions to prevent recurrence). Also record actions which were taken during the event which were successful/satisfactory

Specific action required/Learning outcomes

Specific measurable action points should be agreed within a meeting of the clinical / management team and documented to address the specific risk

4

issues recorded within the form. The action points should be allocated to an individual to oversee and should be time-bound

Timescales and responsibilities

Record details of who is responsible for each action and the date by which it is to be completed

Review of actionsThis will be carried out at a meeting of the clinical / management team at a later stage in the process when all action points have been completed. The review will focus on the causes of the incident (good or bad) and will focus on the adequacy of the response and the continuity of the learning points (again good or bad) which have arisen.

5.2. All Significant Event forms are to be filed collectively and separate from the patient’s clinical record (in cases where the event relates to a patient) to ease subsequent retrieval and review.

5.3. In addition to the Significant Event Report forms and the Review form, the meetings at which the events were discussed should be separately minuted and a detailed account of the discussion surrounding the event itself should be made within the body of the minutes. These meetings may be multi-disciplinary.

5.4. The fully completed event forms, extracts of the minutes of the meetings, summary report can then form a complete file for an internal or external audits or inspections.

5.5.5.6.

6. Appraisal

6.1. Appraisal has a number of components and part of this is the presentation of evidence of a robust system of audit, significant event reporting and clinical risk assessment. One of the keys to this is the ability to demonstrate reflective practice – that issues have been identified, acted upon, and that resulting change has been successful. To this end it is recommended that an annual review of all significant events takes place where the various

5

learning points and actions taken can be audited, validated and recorded, and the records of these can feed into the appraisal process.

6.2. It is likely that events arise from clinical, administrative and other areas of the business, and the validation and audit discussions may involve nursing, reception or other staff effected by either the original incident or by the subsequent changes. The effectiveness of the changes can then be evaluated.

6.3. Serious Incident Management

Serious Incidents (SI) will be investigated following the guidance in the National Framework for Reporting and Learning from Serious Incidents. Guidance regarding the Serious Incident Timeline is set out at Appendix 8.

All Never Events must be declared as Serious Incidents.

The Statutory Duty of Candour must be enacted for all Serious Incidents please see Connect healthcare procedure for Being Open and Duty of Candour Policy & Procedure for full guidance

All Serious Incidents must be investigated using Root Cause Analysis methodology (Appendix 5 refers)

Once completed and approved, the reports and its findings must be shared with the patient and /or relevant other parties

If during an investigation further evidence/information becomes available that identifies that the incident does not fit the Serious Incident criteria a request for downgrade can be discussed with the Commissioners

All Completed incident investigations will be presented at the Connect Healthcare Board including monitoring of actin plans and final incident closure

Sharing learning will be identified as part of each individual incident investigation; this may be with individuals, groups of clinicians or organisation wide. Learning will also be shared via the Newsletter and

6

6.4. Reporting of incidents to external agencies

o Rotherham Clinical Commissioning Group

All significant incidents will be report to RCCG and NRLS

Care Quality Commission :o Certain deaths of people using the serviceo Allegations of Abuseo Events that stop or may stop the service from running safely and

properlyo Serious injuries to people who use the service

Medicines & Healthcare products Regulatory Agency (MHRA ):o Any incident involving a medical device that has, or could have,

caused harm to a patient or the user of the device should be reported to the MHRA. This includes user errors and safety concerns.

Connect Healthcare’s Medical Devices Safety Officer is responsible for ensuring the reporting of any relevant medical device incidents to the MHRA.

NHS England – certain types of information governance and cyber security incidents must be reported to NHS England. The responsibility to ensure that the relevant incidents are reported lies with the Information Governance Assurance and Security Manager.

Some incidents may be classified as Information Governance Serious Incident Requiring Investigation (SIRI). Since June 2013 all NHS organisations processing health and adult social care personal data must use the IG Toolkit Incident Reporting Tool to report level 2 IG Serious Incidents Requiring Investigation (SIRI) to the Department of Health (DH), NHS England and the Information Commissioner’s Office (ICO). IG SIRI

7

functionality was extended in early 2015 to enable capture of cyber related incidents.

A cyber-related incident is anything that could compromise information assets within cyberspace. “Cyberspace is an interactive domain made up of digital networks that is used to store, modify and communicate information. It includes the internet, but also the other information systems that support our businesses, infrastructure and services.” Source: UK Cyber Security Strategy, 2011

NHS Protect – certain incidents relating to fraud, corruption and security (including violence and aggression) should be reported to NHS Protect. The responsibility to ensure that all relevant incidents are reported lies with the Local Security Management Specialist (LSMS) and the Counter Fraud Specialist (CFS).

Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR ) – certain staff and patient injuries and occupational diseases must be reported to the Health & Safety Executive (HSE) via RIDDOR.

Certain other incidents may be reportable to one or more enforcement agencies, including but not restricted to, the Health and Safety Executive, South Yorkshire Fire and Rescue Service, The Environment Agency and Rotherham Metropolitan Borough Council. These reports shall be co-ordinated by the Safety, Fire & Security Management Department.

Health Protection Agency (HPA ) – Outbreaks, Serious Incidents of communicable diseases and other health protection incidents (whether related to failures of healthcare or not) are reportable to the HPA.

The Police - certain types of incidents (actual or suspected) should be reported to the Police. For e.g.:o Theft.o Fraud.o Abuse.o Suspected arson.o Terrorism and chemical, biological, radiological or nuclear incidents.

8

o Unexpected patient deaths or serious harm in which there is a suspicion of malicious intent

Maternal deaths – all mothers dying within 12 months of the birth of a baby must be investigated as a Serious Incident – MPMN (Maternal and Perinatal Mortality Notification.)

6.5. Supporting staff

Involvement in an incident that resulted in harm to a patient can have profound consequences on those staff members involved who may experience a range of reactions from stress to depression to shame and guilt. The high personal and professional standards of most clinicians and other NHS staff may make them particularly vulnerable to these experiences. Connect Healthcare will use the Just culture guidance to support a consistent approach to investigation.Any HR / conduct issues arising from a clinical incident will be separate to any incident investigation. Support will be offered to all staff involved in any clinical incident.

6.6. Duty of Candour

Healthcare professionals have a long established professional duty of candour to be honest and open with patients when something goes wrong and this includes providing an apology.

In November 2014 the Care Quality Commission’s Regulation 20: Duty of Candour was introduced. It is a statutory duty placed on healthcare providers. It encompasses all aspects of professional duty of candour but also includes the actions that providers must undertake when the threshold of a notifiable safety incident (see definition in 4.4) is reached. These are:

Carry out a thorough investigation into the causes of the incident and share relevant details with the patient and/or relevant other

Provide an apology in writing, following the verbal apology in person Provide reasonable support to the patient in relation to the incident Establish a formal and defined process of harm disclosure as part of the

providers governance processes

9

The statutory duty is a duty on health providers. However, individual clinicians are relied on to discharge it on behalf of the organisation. Regulation 20 makes clear that cooperation between a healthcare organisation and its staff is vital. Further information can be found in the Duty of Candour and being open procedure.

7. DEFINITIONS AND ABBREVIATIONS

7.1. Definitions

Incident – any unexpected or unintended event or circumstance that leads to, or could have led to, harm, loss or damage to people, property or reputation.

Patient Safety Incidents (PSI) – any unexpected or unintended event or circumstance that results in, or could result in, harm to a patient.

Examples

Any incident that gives rise to actual or possible physical injury or patient dissatisfaction. This includes adverse clinical events.

An injury sustained by a member of staff during the course of work or sustained as a result of an act of violence upon a person at work.

Any near miss i.e. an incident which if it did not cause harm could do so if it happened again.

Medication errors/issues Death on the premises New cancer diagnoses Deaths where terminal care has taken place at home Suicides Mental Health Act admissions Child protection cases Inaccurate or incomplete medical records Delayed or missed diagnosis Referral difficulties Failure in message handling Events which have resulted in a complaint Health and Safety issues or incidents Emergency situations involving patients or members of the public

10

Non-Patient Safety Incidents - any unexpected or unintended event or circumstance that results in, or could result in, harm to a member of staff (including contractors) or a visitor or loss/damage, including financial and reputational, to the Trust.

Notifiable Safety Incident for health service bodies – any unintended or unexpected incident that occurred in respect of a patient’s care that, in the reasonable opinion of a healthcare professional, could result in, or appears to have resulted in:

the patient’s death; severe harm; moderate harm; prolonged psychological harm.

Identifying something as a notifiable safety incident does not automatically imply error, negligence or poor quality care. It simply indicates that an unexpected and undesirable clinical outcome resulted from some aspect of the patient’s care, rather than their underlying condition

All notifiable safety incidents trigger the Statutory Duty of Candour (please refer to the Being Open and Duty of Candour Policy & Procedure). Many Notifiable Patient Safety Incidents will be declared as Serious Incidents.

Severe harm - a permanent lessening of bodily, sensory, motor, physiologic or intellectual functions, including removal of the wrong limb, or organ or brain damage, which is directly related to the incident and not to the natural course of the patient’s illness or underlying condition.

Moderate harm: significant harm which is defined as the temporary lessening of bodily,

sensory, motor, physiologic or intellectual functions that is directly related to the incident and not to the natural course of the patient’s illness or underlying condition and

moderate increase in treatment, which is an unplanned return to surgery, an unplanned readmission, a prolonged episode of care, extra time in

11

hospital or as an outpatient, cancelling of treatment or transfer to another treatment area (such as intensive care).

Prolonged psychological harm - psychological harm which a patient has experienced or is likely to experience, for a continuous period of at least 28 days.

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 the Trust are so significant, that they warrant using additional resources to mount a comprehensive response. They can extend beyond incidents that affect patients directly and include incidents that may indirectly impact on patient safety or the Trust’s ability to deliver on-going healthcare. (Appendix 7 refers).

Never Event - a sub-set of Serious Incidents and are defined as 'serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’. All reported incidents will be reviewed to ensure that no Never events are identified.

Near miss/prevented incident – any incident that had the potential to cause harm but was prevented, resulting in no harm.

Root Cause Analysis – a systems approach to investigating an incident to understand how and why it happened and therefore identify effective actions to prevent the incident occurring again.

STEIS (Strategic Executive Information System) – a Department of Health management information system used to collect information about NHS organisations, including Serious Incidents.

8. REFERENCES

National Patient Safety Agency (NPSA) Seven Steps to Patient Safety. The full reference guide. Available at www.npsa.nhs.uk/sevensteps April 2004 ,

Safeguarding Children: Under Working together to Safeguard Children: Every Child Matters 2006.

12

NHS CSP Publication 11 ‘Managing incidents in the Cervical Screening Programme.’

NHS BSP Publication 44 ‘Guidelines for managing incidents in the breast screening programme’

NHS BCSP Publication 6 ‘Quality Assurance guidelines for Colonoscopy’

NHS England. National Serious Incident Framework March 2015www.england.nhs.uk/ourwork/patientsafety/

NHS England. National Reporting and Learning Systemwww.england.nhs.uk/ourwork/patientsafety/report-patient-safety/

NHS England. National Safety Standards for Invasive Procedures (NatSSIPs). 2015.www.england.nhs.uk/patientsafety/never-events/natssips/

Public Health England. Managing safety incidents in NHS Screening Programmes. 2015www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes

http://www.hse.gov.uk/pubns/indg453.pdf

13

APPENDIX 1

14

Appendix 1 – Significant Event Record Template

NAME OF PERSON COMPLETING THIS FORM:

DATE & TIME OF EVENT:

DETAILS OF WHERE THE EVENT TOOK PLACE:

NAMES OF OTHER PEOPLE INVOLVED:

BRIEF DETAILS OF THE EVENT:(provide a factual account of what happened in chronological order and give details of actions taken)

IMPORTANCE LEVEL: URGENT/ROUTINE(delete as appropriate)

15

Please return completed form to: Lead Development Nurse

………………………………………………………………………………………………..

16

Appendix 2 – Significant Event Review Template

DATE OF REVIEW:

THOSE PRESENT AT REVIEW:

SUMMARY OF THE EVENT (include details of actions which went well):

KEY RISK ISSUES:

SPECIFIC ACTION REQUIRED (including actions to prevent recurrence) & LEARNING OUTCOMES:

TIMESCALES & RESPONSIBILITIES FOR ACTIONS:ACTION POINT WHO BY

WHEN1.

2.

17

3.

REVIEW OF ACTIONS:

18

Appendix 3 – Significant Event Report Template

NAME OF PERSON COMPLETING THIS FORM:

DATE & TIME OF EVENTDETAILS OF WHERE THE EVENT TOOK PLACE:

NAMES OF OTHER PEOPLE INVOLVED:

BRIEF DETAILS OF THE EVENT:

IMPORTANCE LEVEL: URGENT/ROUTINE(delete as appropriate)

Please return completed form to:

………………………………………………………………………………………………..

19

Escalation Procedure including Emergency Cascade

In the event of a serious incident during a session please follow business continuity protocols.

Examples of serious incidents are usually those involving a call out to the emergency services other than 999 calls for admitting a patient.

In an emergency situation staff should take the following actions:

Step 1 Ensure you are safe, if there is an immediate threat to life or property, contact the emergency services.

Step 2Inform on-call manager* of incident.

Step 3 Manager is then responsible for contacting the relevant bodies

Step 4 Manager is required to provide details of the incident, (what, where, when) and their contact details.

Step 5The on-call manager will assist in the coordination, escalation and management of the incident, staff should follow any further direction from them.

20

21