Session 3 - Incident Reporting Policy - Health Partnerships Learning ...

Incident Reporting Policy
Reader information
Reference
NONCLIN/POL/2010/314
Directorate
Professions and Governance
Document purpose To provide guidance to all staff on the process for the reporting
and management of untoward incidents
Version 1.0a
Title
Incident Reporting Policy
Author/Nominated Lead
Title plus contact details
Kieran Colton – Head of Governance and Compliance
Kieran.colton@nottscommunityhealth.nhs.uk
Approval Date February 2010
Approving Committee Quality & Risk Sub-Committee
Review Date February 2013
Groups/staff Consulted Policy Review Group, Risk Manager, Professions & Governance
team & Quality and Risk Sub-committee
Target audience All Staff
Circulation list
All Staff
Associated documents Risk Management Strategy
Serious Untoward Incident Policy
Voicing Your Concerns (Whistle Blowing)
Being Open
Risk Assessment Procedure
Superseded documents None
Sponsoring Assistant Assistant Director of Professions and Governance
Director

Contents
Section
Page
1 Introduction 3
2 Purpose 3
3 Definitions 4
4 Duties 5
5 Communication and Notification 8
6 Reporting to External Agencies 9
7 How to Report an Incident or Near Miss 10
8 Incident Reporting and Investigation 12
9 Approval and Monitoring 12
10 Learning and Sharing Safety Lessons 13
11 Training 13
12 Equality Impact Assessment 13
13 Monitoring Compliance with the Document 14
14 References 14
15 Associated Documentation 15
Appendices
Appendix A How to Report an Incident or Near Miss (Reporting Procedure) 16
Appendix B Risk Grading Matrix 20
Appendix C List of External Stakeholders 22
Appendix D Definitions of Serious Untoward Incidents (SUI’s) 23
Appendix E Senior Manager On-Call Arrangements 25
Appendix F Equality Impact Assessment Tool 26
Appendix G Plan for Dissemination of Policies or Procedural Documents 27
Appendix H Employee Record of Having Read the Policy/Procedure/Guidance 28

1 Introduction
The effective reporting of patient safety and staff related incidents, accidents, near misses and
hazards is an essential component to patient safety and quality improvement within
Nottinghamshire Community Health (NCH). It is vital to the delivery of high quality, safe patient
care and to facilitate organisational learning in preventing recurrence of adverse events.
Effective reporting works to improve patient safety and the well being of staff and visitors to
NCH premises.
This document details the standard requirements for incident reporting. The Policy does not
provide comprehensive details on Incident Investigation and Root Cause Analysis (RCA)
processes used by NCH in the investigation of all incidents, including Serious Untoward
Incidents (SUI’s). Further information on these processes is available in the
Investigation of Incidents, Claims & Complaints Policy
Serious Untoward Incident Policy
The key principles and benefits of the organisations’ Incident Reporting Policy are to:
Safeguard patient care;
Identify trends and potential risk areas for patient safety and quality
improvement;
Maximise organisational learning from the investigation of the incident;
Ensure incidents, where required, are reported to relevant statutory agencies
and external bodies;
Develop a culture of reporting is nurtured through a fair blame approach to
incident reporting and investigation; and
Ensure damage to NCH’s reputation and assets is minimised.
The over-riding purpose of incident reporting is to maximise learning from incidents
and not to apportion inappropriate blame.
Accurate and effective reporting can only occur in a non-punitive environment. Incidents are
therefore managed positively as a way to increase patient safety and improve quality and will
only imply the need for disciplinary action in exceptional circumstances, such as criminal,
reckless or malicious acts and omissions, or gross professional misconduct. All staff are
therefore required to report incidents and to be actively involved in their investigation in a
climate of openness and shared learning.
This Policy has been developed to ensure that NCH has procedures in place to meet Standard
1.5.1 of the NHSLA Risk Management Standards for PCT’s dated April 2009/10 which
describes the process for managing the risks associated with the reporting of all internally and
externally reportable incidents.
2 Purpose
The purpose of this policy is to minimise injury or incident to all, by ensuring that any lessons
learned from any accident, incident, near miss, disease or dangerous occurrence are acted on
so that a similar recurrence is either avoided or the possibility of recurrence is reduced.
It also ensures that required information is passed on to prescribed authorities and affected
person(s) in a proper and prompt manner.

3 Definitions
Accident: Anything that happens without apparent cause
Breach of confidentiality which includes: Finding a computer printout with a header and a
person’s information on it at location outside of any NCH premises/building. Finding any paper
records about a patient/member of staff or business of the organisation in any location outside
of the NCH premises/buildings. Being able to view patient records in the back (or front) of an
employees car (e.g. Doctors and Nurses). Discussing, in person or on the phone, patient or
staff personal information with someone else in an open area where the conversation can be
overheard. A fax, email or letter being received by the incorrect recipient.
Breach of Security:
Loss of computer equipment due to crime or an individual’s carelessness
Loss of computer media e.g. floppy disc, CD due to an individual’s carelessness
Accessing any part of a database using someone else’s authorisation either
fraudulently or by accident
Trying to access a secure part of the organisation using someone else’s PIN number,
swipe card
Finding the doors and/or windows have been broken and forced entry gained to a
secure room/building
Information Security Incident: any event that has resulted or could result in;
The disclosure of confidential information to any unauthorised person
The integrity of the system or data being put at risk
The availability of the system or information being put at risk
An adverse impact e.g.
o Embarrassment to the NHS
o Threat to personal safety or privacy
o Legal obligation or penalty
o Financial loss
o Disruption of activities
Hazard: ‘a situation with the potential to cause harm or damage’
Hazards are situations with the potential to cause harm or damage. They could include
faulty equipment, worn or loose floor coverings, irritant chemicals etc.
Incident Report Forms must be completed for all hazards
Staff are responsible for not only completing the Incident Report Form but also taking
reasonable steps at the time to minimise the risk of injury from the identified action
Near Miss: ‘any patient safety incident that had the potential to cause harm but was
prevented, resulting in no harm’
A Near Miss is when any incident that had the potential to cause harm but was
prevented, resulting in no harm
It is important Near Misses are reported to identify and effectively manage the risk of
reoccurrence
Research has shown that for every serious incident, there will have been many more
similar Near Misses which were not reported because no harm resulted
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Other incidents: Some incidents may impact on other parts of the NHS e.g. a computer virus
and if this is the case the incident should be reported to the IT Helpdesk (01623 410310 Ext
4040). All Information Security Incidents will be reported to the Risk Management Team.
Other Incident Categories
Patient safety incidents
Accidental injuries
Slips, Trips and Falls
Work related ill-health
Unusual or dangerous occurrences
Medication errors
Adverse drug reactions
Patient safety incidents
Missing health records
Violence or damage to property
Equipment failures
Fraud etc.
This list is not exhaustive but gives some examples of the wide range of adverse events that
are categorised as reportable incidents.
Patient Safety Incident: ‘an unintended or unexpected incident that did lead to harm for one
or more persons receiving NHS-funded care’
Reportable Incidents: any event which contains one or more of the following components:
Standards of patient care full below those expected to deliver good patient care
An incident that places patients, staff or visitors at unnecessary risk
An incident that may attract adverse legal or media attention
There is risk or damage to property
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR
95)
A number of incidents and accidents must be reported to the Health and Safety Executive
under the RIDDOR regulations as defined below:
Dangerous Occurrences: A ‘dangerous occurrence’ is a term used in RIDDOR 95,
which specifically denotes types of incidents that are reportable under these
regulations
Major Injury: RIDDOR regulations do not define a major injury; the list in Appendix A
of the Incident Reporting Procedure identifies the types of injuries that are reportable
Further details can be obtained from the RIDDOR web site: http://www.riddor.gov.uk/
Serious Untoward Incidents (SUIs) involve the occurrence of the most serious incidents,
examples include (See Appendix D and also Serious Untoward Incident Policy)
Significant harm
Unexpected death
Death directly related to an adverse event
Substantial damage or loss to NCH assets
Adverse media interest
Death of a prisoner in receipt of care
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Ward closure
Child death
Serious sexual assault
Risk to NCH’s reputation; and Infection outbreaks
Significant loss of confidential information or patient identifiable information
Staff: ‘Staff, volunteers, students and sub-contractors working for Nottinghamshire
Community Health and independent contractors commissioned by NCH.
4 Duties
Managing Director:
The Managing Director has overall responsibility for risk management within NCH
Assistant Directors/Associate Directors
Ensure all staff in their Directorate are informed of the need to report incidents
which arise out of the activities of the Directorate
Ensure all directly employed staff understand the incident reporting system and
receive feedback from incidents reported
Ensure contractors and volunteers are aware of the Incident Reporting Policy
Allocate sufficient resources (both financial and human) for incident investigation
and follow up
Ensure any recommendations made as a result of investigations are put into place
Locality Service Managers/Heads of Service
Ensure all staff, bank staff, agency workers and contractors under their control
understand and follow this policy accordingly
Ensure that all incidents within their sphere of responsibility are reported
Grading all accidents as soon as possible in accordance with the Matrix in this
policy. (See How to Report an Incident or Near Miss Appendix A)
Liaise with Occupational Health team regarding any health issues related to the
health of the injured person
Report intentional assault on staff to the Risk Management Team; who will report to
the Local Security Management Specialist (LSMS) Officer
Ensure that all incidents classified as Major or above are reported immediately to
the Risk Management Team based at Ransom Hall
Ensure that all other incidents are reported to the Risk Management Team within
24 hours of the incident occurring or 1 working day
Undertake investigation as appropriate and completion of the manager’s action
section of the incident report form and returned to the Risk Management team
based at Ransom Hall within 2 weeks from the date of the incident.
Ensure recommendations and actions are carried out as a result of any
investigation
Monitor information reported on the incident forms for accuracy and completeness
Ensure that any procedures within their area take account of incidents which have
been brought to their attention
Ensure that serious incidents are brought to the immediate attention of their Line
Manager or Assistant Director
Where appropriate obtain witness statements
Make safe any area or equipment following an accident and retaining equipment for
inspection where required
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Ensure that risk assessments are reviewed or carried out on all significant identified
hazards and appropriate action plans put in place to reduce risks to an acceptable
level. The results of those risk assessments must be communicated to all those
who may be at risk
Provide feedback to directly employed staff on trends, serious incidents, results of
investigations, recommendations and any learning opportunities
Risk Manager/Health, Safety & Risk Facilitator/Risk Management Team must:
Collate, review and support managers with incidents reported
Support local managers in the investigation process (to be decided case by case)
on incidents
Compile quarterly summary reports on incidents and review recorded incidents to
identify trends
Ensure that all reports are anonymised so that patients cannot be identified from
them
Bring any incidents or trends of particular importance or giving rise to immediate
concern to the attention of the Assistant Director of Professions and Governance,
Head of Governance & Compliance and/or the appropriate Assistant Director
Ensure lessons learned are cascaded and embedded in practice. This will be done
through discussion in team meetings, training, newsletter, posters and intranet
Highlight NCH wide incident trends to the staff and Committees as required on a
quarterly basis, or more frequently if required
Ensure aggregated qualitative and quantitative data on incidents is produced within
the quarterly incident reports. The qualitative data will include types and number of
incidents, service affected, risk severity comparison with previous quarter
Ensure that all reports do not contain any information that would allow the patient to
be identified
Ensure any risk discovered from trends and themes in the aggregated data is
transferred into the appropriate risk register.
Ensure the NCH audit program is informed of risks to enable adaptation to
encompass auditing of learning within the agreed timeframe to ensure staff alter
their practice in response to lessons learnt
Ensure information related to NCH performance in relation to numbers of incidents
and trend analysis are presented to the appropriate Committee, raise awareness of
activity and to engage in the processes of organisation wide learning and
development
Ensure that lessons learnt from trend analysis result in a change in organisational
culture and practice through a robust risk register process
Ensure lessons learned are cascaded and embedded in practice. This will be done
through discussion in team meetings, training, newsletter, posters and internet and
the National Patient Safety Agency (NPSA)
Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
(RIDDOR) accidents/incidents to the Health and Safety Executive (HSE)
Ensure that accidents/incidents are appropriately investigated, and where
necessary remedial measures taken
Maintain an appropriate filing system for hard copy incident report forms
Produce collated reports on incidents for the Health and Safety Group
Forward all incidents of intentional assault and verbal abuse to the Local Security
Management Specialist (LSMS)
Report details of patient related incidents to the NPSA under the National
Reporting and Learning System (NRLS)
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Report details of other incidents to the statutory agencies as necessary (See How
to Report an Incident or Near Miss Appendix A)
All Employees
All employees (including placement students, sub-contractor staff, and volunteers) are
responsible for:
Verbally reporting all incidents and near misses (including violence and verbal
abuse) to their manager as soon as possible
Ensure that all reports of incidents which are categorised as Major or above are
reported immediately to their Line Manager/Service Lead/Risk Management Team
Completing the NCH Incident Report Form within 24 hours of the incident
occurring, either by them or if incapacitated, by a nominee and fax to the Risk
Management Team at Ransom Hall 01623 781747 and then hand original form to
their line Manager
Bringing to the attention of their manager or supervisor any incidents which
resulted in, or had the potential to result in injury, loss or damage (i.e. near misses)
Co-operating in any investigation and providing relevant information to assist in
identifying the cause of the harm
Immediate action must be taken to ensure the safety of staff, patients and other
members of the public before an Incident Form is completed
Role of the Quality & Risk Sub-Committee
The NCH Managing Board has devolved to the Quality and Risk Sub-committee responsibility
for risk management. The Terms of Reference for the Quality & Risk Sub-Committee
(Q&RSC) are included in the Risk Management Strategy.
The Q&RSC receives regular incident reports demonstrating trend analysis and any actions
taken to mitigate the risks.
The responsibility for the completion of action plans, developed in response to incidents record
as Major or above, SUI’s incident investigations, and the effectiveness of any risk reduction
measures will be reported to and co-ordinated by the Q&RSC with the support of the relevant
service (Clinical or Corporate) or groups for specific incident types.
5 Communication and Notification
The Locality Service Manager/Head of Department/Senior Manager as appropriate has a
responsibility to ensure that staff or other persons involved in the incident have received a full
explanation and are made aware of any further implications concerning what has happened.
Those involved in the incident should be kept up-to-date with progress on investigating the
incident.
Communication with and Support for Staff
Nottinghamshire Community Health is committed to developing a culture which allows staff to
raise concerns through appropriate channels, particularly in relation to patient safety. The
systems and processes for reporting incidents and raising concerns will be clearly
communicated to staff and staff will be proactively encouraged to raise concerns. Staff will
also be advised of and have access to the Policy for Voicing Your Concerns (Whistle
blowing). Although NCH would expect that this would only be required in exceptional
circumstances as all senior managers will be responsible for ensuring staff have access to
more appropriate routes.
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Following a reported incident, regardless of severity level it is essential that the staff are:
appropriately supported by line managers, involved in any subsequent investigation and
advised of the investigation outcomes and recommended changes to practice.
Communication with and Support for Victims, Perpetrators, Families and Carers
Following an Incident
Nottinghamshire Community Health will expect that following any incident those involved in the
incident both staff and patients will be offered information and support commensurate with the
level of the incident.
It is also important to ensure that where an incident has occurred involving a patient(s), the
patient is kept informed as to the progress and outcome of any investigation and /or outcome.
Subject to confidentiality provisions, family and carers should also be informed. Such
communication should be clearly recorded within the incident record. Communication should
be maintained with the patient /carer or family for as long as this is necessary.
Communication with the patients and/or the relatives, staff or visitors may need to be both pre
and post investigation dependant on the incident grading and investigation.
Any information given to patients, staff or family and carers needs to be documented by the
person who has provided the information in the incident record. This communication needs to
follow the principles of ‘being open’ as described in the Being Open Policy.
Media Involvement
The Head of Department/Service has a responsibility to ensure that staff affected by or
involved in an incident are informed before any media are involved. The investigating manager
should work closely with the Head of Communications to ensure that this is guaranteed. It is
also important that all staff ensure that no information is given to the media; all media
requested must be referred immediately to their appropriate Assistant Director and/or the
Head of Communications who are based at Ransom Hall.
6. Reporting to External Agencies
NHS Nottinghamshire County and East Midlands SHA
All serious untoward incidents, both clinical and non-clinical will be reported via STEIS by the
Head of Governance and Compliance.
National Reporting Learning System (NRLS)
All patient safety incidents for NCH will be reported, electronically via DATIX, to the NRLS by
the Risk Manager. This contributes to national learning about patient safety. Reports will be
received from the NRLS and distributed through the organisation, which can be used to
benchmark incident reporting with other organisations and identify areas for improvement.
Health and Safety Executive – RIDDOR
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 came into
force on 1st April 1996. NCH must report deaths, major injuries, and accidents resulting in
over 3 day injury, diseases, dangerous occurrences and gas incidents. The Service
Managers/Heads of Service/Team Leaders will carry out RIDDOR reporting, to the HSE, for
NCH. When an incident has been identified as RIDDOR reportable, the Health, Safety & Risk
Facilitator should be notified as soon as possible. In serious incidents resulting in major injury
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or death, the Health and Safety Executive need to be alerted immediately
(www.riddor.gov.uk). Outside of normal working hours the senior manager on-call should do
this. If there is an accident connected with work (including an act of physical violence)
resulting in an employee suffering an over-three-day injury it must be reported in compliance
with the above regulations within 10 days. An over-3-day injury is one which is not ‘major’ but
results in the injured person being away from work OR unable to do their full range of their
normal duties for more than three days. It is the manager’s responsibility to ensure that
the Health, Safety & Risk Facilitator is contacted within 24 hours.
The Health and Safety Executive will require the following information: -
Date and time of incident
Location of incident
Name, home address, gender and status of persons involved / affected
Details of any injuries
Confirmation as to whether the situation is under control or whether assistance
is required
Brief outline of the circumstances of the incident
Details of any witnesses.
Medicines and Healthcare Products Regulatory Agency (MHRA)
Where a serious incident involves a medical device the NCH nominated liaison officer with the
Medicines and Healthcare Products Regulatory Agency (MHRA) must be contacted within 24
hours. The liaison officer for NCH is the Health, Safety and Risk Facilitator. An appropriate
senior manager will be responsible for ensuring that the material evidence is labelled and kept
secure. The Senior Medicines Management Advisor will report adverse reactions to
medication to the MHRA.
Communicable Diseases
The Consultant in Communicable Disease Control (Health Protection Agency) should be
contacted in the event of an infectious disease outbreak defined as two or more cases
connected by time and place and any serious single infection with public health implications.
The most senior manager on duty should notify the HPA as soon as an outbreak has been
identified.
Other External Agencies
A list of other external agencies to which incidents and near misses may require reporting to
are set out in Appendix C. Reporting to these agencies will be undertaken by the Risk
Manager with support from the Risk Management Team and relevant information provided
from service teams.
7. How to Report an Incident or Near Miss
All incidents and near misses should be reported to the line manager as soon as possible after
the event. If the line manager is not available report to the next available senior member of
staff.
Out of hours contact the Senior Manager on call by telephoning 0115 934 3236 (See Appendix
E –Senior Manager On-Call Arrangements)
All incidents, near misses and serious untoward incidents must also be recorded on the NCH
Incident Report Form which are available in all departments and clinical areas within the
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Incident Reporting Folders (a complete list of all the locations is available on the NCH Intranet
site).
Wherever possible the Incident Report form should be completed and faxed to the Risk
Management Team at Ransom Hall (Save Haven Fax 01623 781747) immediately or as a
minimum within 24 hours of the incident occurring. The original Incident Report (Part 1)
and Part 2 should be sent immediately to their Line Manager for grading and further
investigation (See also Appendix A).
The person involved in or identifying the incident should complete the incident report.
In instances where a member of staff is unable to complete the form due to illness or injury,
the senior person on duty should complete the incident report form.
Where an incident results in an absence from work of more than three consecutive days
(excluding the day of the incident, but including week-ends, bank holidays or days off) then the
Line Manager must notify the Health, Safety & Risk Facilitator as soon as possible, in order
that the Health and Safety Executive can be informed within ten days of the accident or
incident. This is a legal requirement under RIDDOR.
Describing the Incident or Near Miss
A description of the Incident or Near Miss should include:
a full, clear and accurate description of the incident and relevant circumstances
recording facts and not subjective opinions
an outline of what was happening immediately prior to the incident occurring and
the exact location of the incident
a clear description of any relevant equipment involved, including asset inventory
ref. serial number, make, model etc
environmental details such as weather and lighting where relevant, and details of
any protective equipment, clothing or footwear
sketch(s)/or photographs should be attached if it assists in making the report
clearer
details of the identity of any witnesses to the event.
Special Actions Relating to Serious Untoward Incidents:
In addition to reading this section all staff should make themselves aware of the
Serious Untoward Incident Policy
Reporting Process in Hours
Where it becomes apparent that the incident is serious (Appendix D gives examples of
incidents that should be reported as a SUI) it must be reported immediately to the appropriate
Assistant Director/General Manager/Head of Governance & Compliance in addition to
completion of the usual incident report form.
The SUI lead (Assistant Director of Professions and Governance) must also be informed and
is responsible for ensuring that the incident is reported on the STEIS system (Strategic
Executive information System ) within 24 hours.
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Out of Hours
If the incident has occurred out of hours telephone the call handling service on 0115 934 3236
who will notify the Senior Manager on call. (See Appendix E)
8. Incident Reporting and Investigating
The timely reporting and investigating of incidents is essential in order to improve patient
safety. Through the identification of actual or potential (near miss) incidents, the subsequent
investigation to identify what, how and why it happened and the implementation of change
should reduce or prevent the recurrence of similar incidents. The process for reporting and
investigating incidents will vary depending on the severity of the incident, the details of which
are provided in the NCH Guidance Document for the Investigation of Complaints, Incidents
and Claims.
Incident Grading and Appropriate Levels of Investigations
All incidents should be graded using the grading matrix set out on Appendix B of this
document. The basic principle is to multiply the consequence by the likelihood. The resulting
number is the risk grade.
Level of Investigation
The level of investigation is dependent on the outcome of the risk grade of the incident.
Level of risk
Risk score 0 to 10
Level of Investigation
Investigated by service with advice and guidance from Risk
Management Team and includes outcome on Part 2 of the
Incident report form
12 to 20 Investigated by Service with direct input and review by Risk
Management Team – outcome record on Part 2 of the Incident
Report Form.
Mangers should adopt the Investigation tools identified within the
document “Guidance on Conducting Investigations of Complaints,
Incidents and Claims”
SUI’s
Some incidents graded between 16 and 25 will require a more
detailed report. Guidance should be sought from the Risk
Management Team
Investigated in line with the Serious Untoward Incident Policy
9. Approval and Monitoring
To ensure appropriate change is made to reduce the likelihood of an incident recurring there
needs to be a system for the approval and monitoring of action plans. It is expected that
remedial action will be taken in response to all incidents and near misses but that the level of
approval and monitoring will be dependent upon the severity. All incidents with a severity
rating below Major will have their actions plans/learning points agreed locally and with
appropriate input from the NCH Risk Management team. Those plans will then be monitored
through the DATIX risk management system by the NCH Risk Management Team.
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All Action Plans relating to incidents or near misses grade Major or above will be approved
and monitored by the Q&RSC.
10. Learning and Sharing Safety Lessons
The reporting, reviewing, investigating and acting upon incidents is critical to the delivery of
safe and effective services. This is essential for all incident types ranging from near misses to
serious untoward incidents. To ensure that NCH learns lessons from reported incidents the
following will be undertaken -
Analysis of trends emerging from high numbers of incidents involving either a
specific type of incident, an individual member of staff, a individual patient or
particular service.
Incident review which will incorporate a root cause analysis of all incidents
classified as Catastrophic or a SUI.
Analysis of all reported incidents quarterly.
The Learning Form Patient Experience Group will review the learning form a variety
of sources such as Incidents, Complaints, Claims, Patient Experience and
identified good practice. Such learning and good practice will be shared via team
meetings, training events, newsletters and the usual service structures.
Lessons requiring instant dissemination will be cascaded through the NCH Safety
Alert Broadcast System.
Improvement will be monitored via the Q&RSC.
The reporting of incident analysis and lessons learnt to Managing Board will be through the
Q&RSC and the Governance Committee following analysis by the various relevant working
groups.
11. Training
Nottinghamshire Community Health will ensure that all staff will have access to induction and
ongoing training in the reporting and handling of Incident Report and investigation.
Staff Group Type Frequency
All Staff Groups
General Risk Management
including Incident Reports,
Induction
3 years
General Principles Risk
Assessment
Band 6 and above
Incident Investigation and Managers Induction
Associates/Directors
General Managers
Service Managers
Governance 6 and above
Band 8 and above
Governance Team and
where required Role Specific
Risk Assessment
SUI Investigation
(Including learning
lessons)
Risk Management
Risk Register/Assurance
Framework
Risk Management
DATIX
NRLS
STEIS
3 years
3 years
3 years
2 years
12. Equality Impact Assessment
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Nottinghamshire Community Health aims to design and implement services, policies and
clinical/non clinical procedures with measures that meet the diverse needs of our service,
population and workforce, ensuring that none are placed at a disadvantage over others.
All policies and clinical/non clinical procedures should be developed in line with the NHS Notts
County Equality and Diversity Policy (2008), and need to take into account the diverse needs
of the community that is served. The Equality Impact Assessment tool is designed to help
consider the needs and assess the impact of the policy and clinical/non clinical procedure
being developed (See Appendix F), and must be completed before approval/ratification can
take place.
13. Monitoring Compliance with the Document
Nottinghamshire Community Health (through the Risk Management Team) will monitor the
effectiveness of this policy through key performance indicators (KPIs) which will include an
annual review.
The process for involving and communicating with internal and external
stakeholders to share safety lessons
The process for following up relevant action plans; through reports from DATIX for
low level risk and the work of the Q&RSC for higher level risks.
NCH regularly uploads to the NPSA National Reporting Learning (NRLS) system
Lessons learnt from analysis result in change
Process for reducing risk identified through incident reports
75% of incidents have a completed management action section within 2 weeks of
the incident occurring
Quarterly incident risk management reports contain incident and causal factors
trend analysis
At least 2 Lessons Learnt reports (Shared Experience Newsletters) are produced
and disseminated each year
An annual risk management report containing results of the audit and improvement
actions is produced for the Q&RSC responsible for overseeing risk management
14. References
Health & Safety Executive. (1995). Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR Explained, Version 6), Suffolk: Health and Safety
Executive. Available at: http://www.hse.gov.uk/riddor/index.htm.
Health and Safety (Consultation with Employees) Regulations 1996. (Statutory Instrument
1996 No. 1513). London: The Stationery Office. Available at: www.opsi.gov.uk
Health & Safety Executive. (1996). A guide to the Health and Safety (Consultation with
Employees) Regulations 1996 (L95). Suffolk: Health and Safety Executive. Available at:
www.hsebooks.com/
Public Interest Disclosure Act 1998, Chapter 23. London: The Stationery Office. Available at:
www.opsi.gov.uk
Department of Health. (1998). Health Service Circular 1999/198, The Public Interest
Disclosure Act 1998: Whistle blowing in the NHS. London: Department of Health. Available at
www.dh.gov.uk/
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Department of Health. (2000). An Organisation with a Memory: Report of an Expert Group on
Learning from Adverse Events in the NHS. London: Department of Health. Available at
www.dh.gov.uk/
Department of Health. (2001). Building a Safer NHS for Patients: Implementing an
Organisation with a Memory. London: Department of Health. Available at www.dh.gov.uk/
National Patient Safety Agency. (2004). Seven Steps to Patient Safety. London: National
Patient Safety Agency. Available at: www.npsa.nhs.uk/
National Patient Safety Agency. (2005). Building a Memory: Preventing Harm, Reducing Risks
and Protecting Patient Safety London: National Patient Safety Agency. Available at:
www.npsa.nhs.uk.
National Patient Safety Agency. (2005). Patient Briefing - Saying Sorry When Things Go
Wrong. London: National Patient Safety Agency. Available at: www.npsa.nhs.uk/
National Patient Safety Agency. (2005). Safer Practice Notice - Being Open When Patients
are Harmed. London: National Patient Safety Agency. Available at: www.npsa.nhs.uk/
Healthcare Commission. (2008). The annual health check 2008/09 Assessing and rating the
NHS. London: Healthcare Commission. Available at:
http://www.healthcarecommission.org.uk/publicationslibrary.
Department of Health. (2008). High Quality Care For All NHS Next Stage Review Final Report.
London: Department of Health. Available at: http://www.dh.gov.uk
National Patient Safety Agency (NPSA). (2009). Never Events – Framework for 2009/10:
Process and action for Primary Care Trusts 2009/10. London: NPSA. Available at:
http://www.npsa.nhs.uk
15. Associated Documentation
All Information Governance Policies
Safeguarding Children Policy
Being Open Policy
Health and Safety Policy
Incident Reporting Procedure
Slips, Trips and Falls Policy
Guidance on the Investigation of Claims, Incidents and Complaints
Policy for the Management of Violence and Aggression (Zero
Tolerance)
Risk Management Strategy
Risk Assessment Procedure
Risk Register Policy
Patient Identification Policy
Safeguarding Adults Policy
Serious Untoward Incident Policy
Medical Devices Procedure
Raising Concerns “Whistle Blowing' Policy
Page 15 of 28

Appendix A
HOW TO REPORT AN INCIDENT OR NEAR MISS
The following is operational guidance on when and how to report an incident or near miss. For full
guidance on untoward incident reporting you should refer to the Nottinghamshire Community Health
Procedure for the Reporting of Incidents and Near Misses.
All incidents and near misses should be reported to the line manager as soon as possible after the
event. If the line manager is not available report to the next available senior member of staff.
Out of hours contact the Senior Manager on call by telephoning 0115 934 3236.
All incidents, near misses and serious untoward incidents must also be recorded on the
Nottinghamshire Community Health Incident Report Form (Example Section 3)
Hard copies of the Incident Report forms are available across the organisation and
the nearest pack of forms to you is identified in Section 1 of this folder.
In all cases the Incident Report form should be completed and submitted within 24 hours of the
incident occurring:
Hard copy Incident Reports: Should be faxed to the Risk Management Team (Ransom
Hall) on 01623 781747
Where the service, team and/or department have the capability to scan the Incident Report
(part1) then they can also email the electronic PDF of the Incident Report to:
professions.governance@nottscommunityhealth.nhs.uk
DEFINITIONS
Incident: – Any event or circumstance involving patients, staff, visitors or contractors that could
have, or did lead to unintended or unexpected harm, loss or damage.
Near Miss: – Any event or omission where an incident almost occurred which had the potential
to cause harm, injury, damage or loss but failed to develop, whether or not as a result of
compensating action.
ROLES AND RESPONSIBILITIES
Employees: - All Employees of NCH have a duty to ensure incidents and near misses are
reported as soon as possible and their manager notified so that the event can be
investigated and measures taken to minimise the risk of a recurrence of the situation.
Managers: - Managers have a responsibility for ensuring that incidents and near misses are
graded and investigated as soon as possible after the event and that measures are taken
to minimise the risk of a recurrence of the situation.
Page 16 of 28

Guidance on completing an Incident Report Form
The Incident Reporting Form MUST be used to record ALL incidents
Record known FACTS only – do not give opinions
The form must be completed within 24 hours of the incident occurring
All staff are required to complete part 1
SECTION ONE (S1)
From the categories stated clearly tick what type of incident has occurred
Date of incident should be noted in the following format: 01 11 08
Time to be shown as the 24 hour clock e.g. 13:45
SECTION TWO (S2)
The exact location of where the incident occurred needs to be given in detail
Examples:
Stapleford Care Centre Consulting room 3
Ransom Hall
External fire escape stairs
Mansfield Community Hospital Inpatients Ward
Clearly tick the relevant box if equipment, medication or violence and aggression was involved or a
contributory factor in the incident
SECTION THREE (S3)
1) Give a brief overview of the actual incident.
2) Write clearly avoiding the use of abbreviations
3) Give brief details of the events leading up to the incident
4) Give details of any person(s) involved - do not name them
5) If medication or equipment was involved, give details e.g. Drug name and dose and/or serial
number of equipment
6) Do not attach any statements or further information to the form (Do not attach patients
clinical records)
It is important that you only state FACT and not opinion
If the incident relates to poor discharge arrangements (Section 5 - Poor Discharge Form) or a
Pressure Ulcer Grade 3 or 4 (Section 6 - Supplementary Information for Pressure Ulcer Incident
Forms) then the appropriate form identified at section 5 and 6 MUST be completed. Guidance on
completing both forms is outlined in Section 4 of the Incident Reporting Folder
SECTION FOUR (S4)
Give names of any witnesses and indicate what status they are e.g. staff, patient, contractor
Give a contact number including the std code e.g. 01623 414114 Ext 4656 etc
Page 17 of 28

SECTION FIVE (S5)
Describe in all stages any actions that have been taken following the accident.
E.g. removed faulty equipment out of use/Reported to Estates/Reported to Police/Referred to Staff
Health
SECTIONS SIX & SEVEN (S6 & S7)
The individual affected by the incident is the person that suffers or could have suffered injury, ill health
or loss.
If the individual affected is a member of staff then section seven must also be completed. The
member of staff must give their actual job title e.g. District Nurse, Pharmacist, Administrator.
Give a contact number and give the full workplace address not just the name of the premises.
The table below has a list of ethnicity groups all coded. The relevant code should be added in section
6.
Asian or Asian
British
Mixed Black or Black British White Other ethnic
group
01 – Bangladeshi
02 – Indian
03 – Pakistani
04 – Other Asian
background
05 – White & Asian
06 – White & Black African
07 – White & Black Caribbean
08 – Other mixed background
09 – African
10 – Caribbean
11 – Other black
background
12 – British
13 – Irish
14 –Other White
background
15 – Chinese
16 – Other ethnic
group
SECTION EIGHT & NINE (S8 & S9)
The person completing the form should enter all details in block capitals. Details of full workplace
address must be given not just the name of the premises. Enter the date you complete the form.
Give full details as stated of their line manager’s details.
ON COMPLETION OF THE FORM
Check the form to ensure all details are correct
Do not attach any further information with the form
Fax the BLUE copy (Part 1) of the form to the Risk Management Team on 01623 781747 or e-
mail an electronic copy to professions.governance@nottscommunityhealth.nhs.uk
Send the blue copy of the form to line manager for completion of part 2 - clearly mark the
envelope e.g. Tanya Jones, District Nurse Team Leader
Remove the white copy out of the incident reporting pad and retain and file in a safe place
Page 18 of 28

SECTION 10 (S10)
PART 2 IS TO BE COMPLETED BY A LINE MANAGER
Consider the incident and look at the initial actions already taken to prevent the incident from re
occurring (actions in part 1, section 5).
Assess the incident using the risk matrix
When scoring the incident think about the potential severity if the incident were to happen
again
Think about how likely it is that the incident could occur again
If the overall risk score is below 8, and the actions in part 1 - section 5 are sufficient then no
further investigation is required
If the overall risk score is between 8 and 12 then further investigation must be carried out.
The rest of this form should be used to record the findings.
If the overall risk score is over 12 than the incident must be reported to the Risk Management
Team immediately on 01623 673847
SECTION 11 (S11)
1) Give full details of the investigation you have undertaken
2) Do not attach any further documents (statements, clinical records etc)
3) Identify how and why the incident happened.
4) Give details of any person(s) involved in the investigation process and identify what role they
played e.g. partners from other agencies, estates manager
5) Give details of any policies/procedures that have been referred to during the investigation
SECTION 12 (S12)
From the investigation note down stage by stage the lessons learnt.
Give simple, clear facts. Each sentence should contain one specific fact.
Example: Lessons learnt from the loss of a data stick.
1) Never put personal information on the data stick
2) Use encrypted data sticks only
SECTION 13 (S13)
Write down stage by stage all the actions that have been has been taken from the lessons learnt.
Example:
1) Purchased encrypted data sticks
2) Ensured all staff have read and understood the Policy for Use of Portable Data Storage devices
Complete SECTION this 14 section (S14) using block capitals
Enter date the investigation completed
Enter full job title e.g. General Manager, Locality Service Manager, Health Visitor Team Lead
Enter full workplace address.
Once completed return the original Part 1 and Part 2 (Blue form) to the Risk Management team; you
should retain a copy for your own records.
The form must be returned to the Risk Management team within two weeks of the date of the
original incident occurring
Page 19 of 28

Appendix B
Risk Grading Matrix
Severity
LIKELIHOOD
1
Insignificant
2
Minor
3
Moderate
4
Major
5
Catastrophic
1 - Rare
2 - Unlikely
3 - Possible
4 - Likely
5 - Almost
Certain
1 2 3 4 5
2 4 6 8 10
3 6 9 12 15
4 8 12 16 20
5 10 15 20 25
Risk
High (H)
Moderate
(M)
Low (L)
Further Action
Risk Priority
Significant Risk. As below plus:
Report to Managing Board identifying treatment options
Quarterly report to the Managing Board monitoring progress on
treatment action plans
Unacceptable Risk. As below plus:
(12 and above) Report to the Governance Committee identifying
treatment options
(12 and above) report to the Q&RSC monitoring progress on
treatment action plans
Acceptable Risk. As below plus:
discuss whether any further action should be taken to reduce
future risk
By Whom
Governance
Committee
Q&RSC
Team Meetings
Risk Matrix – Likelihood
Likelihood rating Description
5 Almost Certain this type of event will happen frequently
4 Likely this type of event will happen, but its not a persistent concern
3 Possible this type of event may well happen (e.g. 50/50 chance)
2 Unlikely unlikely that this type of event will happen
1 Rare cannot believe that an event of this type will occur in the foreseeable future
Page 20 of 28

Risk Matrix – Severity
1 2 3 4 5
Descriptor Insignificant Minor Moderate Major Catastrophic
Over three days off Major injuries, or
Injury
Minor injury or “sick” = RIDDOR long term Death or major
Minor injury not
illness, first aid reportable. 10 days incapacity / permanent
requiring first aid
treatment needed to report to the disability (loss of incapacity
HSE.
limb)
Patient
Experience
Unsatisfactory
patient experience
not directly related
to patient care
Unsatisfactory
patient experience
- readily resolvable
Mismanagement of
patient care – short
term effects
Mismanagement of
patient care – long
term effects
Totally
unsatisfactory
patient outcome or
experience
Complaint/
Claim Potential
Locally resolved
complaint
Justified complaint
peripheral to
clinical care
Justified complaint
involving lack of
appropriate care
Multiple justified
complaints
Multiple claims or
single major claim
Objectives/
Projects
Service/
Business
Interruption
Human
Resources/
Organisational
Development
Insignificant cost
increase/schedule
slippage. Barely
noticeable
reduction in scope
or quality
Loss/interruption >
1 hour
Short term low
staffing level
temporarily
reduces service
quality (< 1 day)
< 5% over
budget/schedule
slippage. Minor
reduction in
quality/scope
Loss/interruption >
8 hours
Ongoing low
staffing level
reduces service
quality
5 -10% over
budget/schedule
slippage.
Reduction in scope
or quality requiring
client approval
Loss/interruption >
1 day
Late delivery of key
objective/service
due to lack of staff
(recruitment,
retention or
sickness). Minor
error due to
insufficient training.
Ongoing unsafe
staffing level
10 - 25% over
budget/schedule
slippage. Doesn't
meet secondary
objectives
Loss/interruption >
1 week
Uncertain delivery
of key objective/
service due to lack
of staff. Serious
error due to
insufficient training
> 25% over
budget/schedule
slippage. Doesn't
meet primary
objectives
Permanent loss of
service or facility
Non-delivery of key
objective/ service
due to lack of staff.
Loss of key staff.
Very high turnover.
Critical error due to
insufficient training
Financial Small loss (> £100) Loss > £1,000 Loss > £10,000 Loss > £100,000 Loss > £1,000,000
Inspection/ Audit
Adverse
Publicity/
Reputation
Minor
recommendations.
Minor noncompliance
with
standards
Rumours
Recommendations
given. Noncompliance
with
standards
Local Media - short
term
Reduced rating.
Challenging
recommendations.
Non-compliance
with core
standards
Local Media - long
term
Enforcement
Action. Low rating.
Critical report.
Multiple
challenging
recommendations.
Major noncompliance
with
core standards
National Media < 3
Days
Prosecution. Zero
Rating. Severely
critical report
National Media > 3
Days. MP Concern
(Questions in
House)
Page 21 of 28

Appendix C
List of External Stakeholders
Incident type Recipient Information reported
RIDDOR incidents Health & safety executive (HSE) Injuries from work based accidents.
Details of incident and persons
involved.
Medicine incidents
Medicines and Healthcare Products
Regulatory Agency (MHRA)
Comprehensive details of incidents
related to adverse drugs reactions.
Medical device related incidents MHRA Comprehensive details related to
devices involved in incident
including manufacture date, expiry
date.
Serious Adverse Blood Related
Events (SABRE)
MHRA / Hospital Transfusion
Committee Via Acute Trust
Haematology Laboratory
Details of incident including initial
findings.
Patient safety incidents NPSA All patient safety incidents including
near-miss events.
Communicable disease outbreaks
and other public health issues
Fire related incidents. Estate
related incidents
Health Protection Agency (HPA)
NHS Estates (NHSME)
Infection control and other public
health incidents with details of
spread of disease, contact etc.
Details of fire incident injuries/death
cause type/quantity loss.
Insurance claims and incidents NHSLA Details and cost of loss/claim.
Environment related incidents e.g
.waste disposal
Data Protection/Caldicott
contraventions
Environment Agency
Dept of Health through SHA
Information on incidents e.g. type of
waste and hazards.
Description of contravention e.g.
patient details disclosed
inappropriately.
Safeguarding Children Local Safeguarding Children Board Details of child protection related
incident.
Safeguarding vulnerable adults Social Services Details of incident to Protection of
Vulnerable Adults Lead [POVA].
The Central Alerting System (CAS) Department of Health Details of actions taken to address
issues contained in alert.
Incident involving a patient detailed
under the Mental Health Act
Incident involving individual in a
registered residential care home
If doctor cannot issue a death
certificate
Mental Health Act Commission
Care Quality Commission
HM Coroner
Details of the individual, type of
section, occurrence.
Details of individual, occurrence.
Details about patient and full
circumstances of death.
Page 22 of 28

Appendix D
DEFINITIONS OF SERIOUS UNTOWARD INCIDENTS (SUIS)
The following are criteria for reporting Serious Untoward incidents to NHS Nottinghamshire
County and the Strategic Health Authority and by implication will be deemed items reportable
under this policy as part of serious incident reporting.
These definitions are currently under review as part of the revised East Midlands SHA
Policy for the Reporting and Handling of Serious Incidents in the East Midlands.
Major Incidents:
Any circumstance which necessitates the activation of the NCHs’ or wider community
Emergency Plan.
Medico-legal incidents:
Suspicion of large scale theft or any incident which may give rise to serious criminal
charges.
Impending court hearing or out of court settlement in cases of large scale litigation
(including negligence claims)
Incidents involving staff:
All incidents where suspension from duty is contemplated and there is likely to be public
interest or the issue is of a serious nature as defined within the following list:
Serious complaints about a member of staff
Suspicion of a serious error or errors by a member of staff
A serious drug error resulting in harm to a patient
A serious breach of confidentiality
Serious verbal and / or physical aggression
Requests for the issue of an Alert letter.
Problems that may have a serious impact on public health or there is a perceived threat
to the health of individual patients
Significant threats to public safety
If referral to the relevant statutory body is contemplated
Suggestions of significant inappropriate conduct, sexual or otherwise
Definite criminal activity or the involvement of the police
Significant inappropriate use of or prescription of controlled drugs
Strong likelihood of stories reaching the media
Mortality / morbidity incidents:
Clusters of unexpected or unexplained deaths
Maternal deaths
Page 23 of 28

The suicide of any person currently in receipt of NHS services including those provided
by primary care practitioners on or off NHS premise, or who have been discharged
within the last 12 months. Suicide is defined as death:
where there is obvious evidence or strong suspicion of self harm, or,
where the above does not apply initially but emerges later from a clinical review or
other review of the case, or,
where the Coroner’s verdict is suicide (or open verdict)
Death or injury where foul play is suspected.
The accidental death of or serious injury to a patient, member of staff or visitor to NHS
premises or involving NHS staff or equipment.
Significant harm to children where reported under child protection arrangements or an
adverse event which results in a serious case review.
Significant harm to adults where reported under vulnerable adult arrangements.
Healthcare associated infection / infection control:
Incidents which result in significant morbidity or mortality and/or
Involve highly virulent and transmissible organisms and/or
Require control measures that have an impact on the care of other patients, including
limitation of access to healthcare services.
These incidents are divided into two bands:
Outbreaks that are sufficiently serious to require the convening of an incident
team and/or
Outbreaks that significantly disrupt services and/or highly virulent and
transmissible with an impact on staff, patients or the community.
Infected healthcare worker or patient incidents necessitating consideration of look back
investigations (e.g. TB, vCJD, blood borne infections)
Significant breakdown of infection control procedures with actual or potential for cross
infection (e.g. release of products from a failed sterilisation cycle, contaminated blood
transfusion).
Premises / equipment incidents:
Serious damage that occurs of NHS premises, or to NHS property, or any incident that
results in serious injury to any individual or serious disruption to services (e.g.
evacuation of patients due to fire)
Failure of equipment so serious as to endanger life, whether or not injury results
Suspicion of malicious activity e.g. tampering with equipment
Circumstances that lead to the provider no longer being able to provide an element of
service.
Page 24 of 28

Appendix E
SENIOR MANAGER ON-CALL ARRANGEMENTS
From 6 April 2008 CNCS (Central Nottinghamshire Clinical Services) provides a single call
handling service for both the County PCT and Nottinghamshire Community Health Senior
Manager on-call rotas.
The contact telephone number is 0115 934 3236
This will access the CNCS call centre who will contact the relevant Senior Manager on-call.
The CNCS team will endeavour to answer all calls within one minute as part of the partner service
agreement with the PCT.
Process for contacting the Senior Manager On-call
1. If there are any urgent security issues, such as a suspected intruder, please phone the
Police straight away as well as making a call to CNCS to contact the relevant On-call Senior
Manager.
2. Please identify to the call handler whether the incident relates to the County PCT or County
Provider services (Nottinghamshire Community Health).
3. CNCS will ask you for the following information:
brief details of the incident
contact details to include:
Your name
Your role
Your team/base
Where you are currently e.g. home, work base etc
Contact telephone numbers
4. CNCS will contact the PCT or NCH Senior Manager on-call.
If the call relates to reporting a Major Incident which requires the PCT input, CNCS will
contact the On Call Director to enable them to escalate the issue to the PCT Chief
Executive.
5. If for any reason you have not heard from the On-Call Manager, please phone again e.g.
after 15 minutes if urgent or half an hour if non-urgent.
6. If CNCS do not receive an answer to calls made to the mobile and home contact numbers
provided for the manager they will leave a message asking them to contact CNCS regarding
an on-call matter and will record the time and date of the call.
7. If not successful in making contact with the senior manager and the matter is urgent, CNCS
will contact the on-call Director. If it is a non-urgent matter they will wait up to half an hour
for the call to be returned.
8. Please ensure the NCH on-call incident log form is completed in full. Completed forms
should be forwarded to the Operations Team at Ransom Hall as soon as possible, certainly
by the next working day.
Page 25 of 28

Appendix F
Equality Impact Assessment Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval.
PROCEDURE NAME
Incident Reporting Policy
Yes/No
Comments
1. Does the policy/guidance affect one
group less or more favourably than
another on the basis of:
Race
Ethnic origins (including gypsies and
travellers)
Nationality
Gender
Culture
Religion or belief
Sexual orientation including lesbian,
gay and bisexual people
Age
Disability - learning disabilities, physical
disability, sensory impairment and
mental health problems
2. Is there any evidence that some groups
are affected differently?
3. If you have identified potential
discrimination, are any exceptions
valid, legal and/or justifiable?
4. Is the impact of the policy/guidance
likely to be negative?
No
No
No
No
No
No
No
No
No
No
No
No
5. If so can the impact be avoided? No
6. What alternatives are there to achieving
the policy/guidance without the impact?
No
7. Can we reduce the impact by taking
different action?
If you have identified a potential discriminatory impact of this procedural document, please
refer it to the sponsoring director, together with any suggestions as to the action required to
avoid/reduce this impact.
For further advice in respect of answering the above questions, please contact the Equality
and Diversity Lead for NCH the Associate Director of Workforce
No
Page 26 of 28

Appendix G
Plan for Dissemination of Policies or Procedural Documents
To be completed and attached to any document which guides practice when submitted to the
appropriate committee for consideration and approval.
Acknowledgement: University Hospitals of Leicester NHS Trust.
Title of
document:
Incident Reporting Policy
Date finalised: Feb 2010
Previous
document
already being
used?
No
(Please delete
as appropriate)
Dissemination lead:
Print name and
contact details
Kieran Colton
Head of
Governance &
Compliance
If yes, in what
format and
where?
N/A
Proposed action
to retrieve outof-date
copies of
the document:
N/A
To be
disseminated to:
How will it be
disseminated, who
will do it and
when?
Paper
or
Electronic
Comments
Dissemination Record - to be used once document is approved.
Date put on intranet
Date due to be reviewed
Disseminated to:
(either directly or
via meetings, etc)
Format (i.e.
paper or
electronic)
Date
Disseminate
d
No. of
Copies
Sent
Contact Details /
Comments
Page 27 of 28

Appendix H
Employee Record of Having Read the Policy/Procedure/Guidance
Title of Policy/Procedure/Guidance:
Incident Reporting Policy
I have read and understand the principles contained in the named policy.
PRINT FULL NAME SIGNATURE DATE
Page 28 of 28