Serious Untoward Incident Policy - Health Partnerships Learning ...

10.5 Progress on the investigation and action plan development for all SUIs will bemonitored through the Governance Committee10.6 When an investigation is complete and within 12 weeks a copy of the report outliningthe process, findings and recommendations of the internal review plus action plan should besent to the Managing Director NCH. The final report will be sent to the GovernanceCommittee and the Professional Executive Team and the resulting action plans will bemonitored for their implementation through the Quality & Risk Sub-committee.The PCT as commissioner will review the SUIs reported to the PCT by the ManagingDirector and may externally monitor the action plans. With agreement an anonomised reportcovering the main findings and recommendations will be shared with other providers whereappropriate.11. Learning from SUIs11.1 The importance of learning from SUIs to ensure they do not reoccur is fundamental todeveloping quality services and minimising risk to patients, staff and the organisation.11.2 It is the responsibility of the Designated Lead Director to meet with individuals /services/agencies involved to share recommendations so that multi-disciplinary learning from theevent will take place.11.3 The Head of Governance & Compliance will ensure that any SUI trends are reviewed inthe Governance Committee and reported to Managing Board where required.Recommendations and changes to practice will be disseminated to the wider organisationthrough appropriate channels to enable organisational and clinical improvements to beachieved as a consequence.11.4 It is particularly important that NCH learns from investigations into serious untowardincidents. NCH needs to ensure that their staff, are genuinely encouraged in performanceimprovement and this culture needs to pervade the process and be paid special attention atthe conclusion of a review.12. Key performance indicators12.1 All SUIs are reported to relevant parties within NCH within four hours of occurrence.12.2 All SUIs are reported to the Head of Communications and from there verbally to thePCT and SHA Communications Team within twelve hours of occurrence.12.3 All SUIs are reported to STEIS/UNIFY within 48 hours of occurrence.12.4 The Governance Committee will receive a summary report of all SUIs and lessonslearned at each of their meetings.12.5 The Quality and Risk Sub- Committee will monitor the implementation of all SUI actionplans.12.6 Any residual risks are monitored and managed through the NCH Risk Register process.15