Incident Management Policy and Procedure 652.0 KB - Oxleas NHS ...

VERSION CONTROLDocument LocationOxleas NHS Foundation Trust IntranetSee under IncidentsChange HistoryVN Owner Changed by Change summary Date1.0 SMG N/A First issue in this format April 20081.1 SMG Susan Owen Added section 2.1 re: submitting forms electronically Section 2.2 amended in light of section 2.11.2 SMG VenuRajagopal2.0 PSG BryonyRobertson Section 2: guidance on reporting natural deaths added Section 2.3 updated re: Coroners Rule 43, reporting viaSTEIS and reporting to commissioners Section 8: Monitoring Statement updated Appendices III and IV updated with new report form andguidance Appendices VII, IX and X added Safety Management group and AIMG removed and replacedwith Patient Safety Group Head of Adverse incidents management role changed toPatient safety lead. Level 3, 4 and 5 incidents should be sent to the PatientSafety Department directly and not via the approvingmanager. Section 2.2 Never events added Safeguarding children references updated Incidents classification chart reviewed Appendix V Critical incident use box removed NHS London report submission deadline changed from 60working days to 45 working days in line with the NHSLondon Appendix 11 added - Borough Template for CriticalIncident/SUI notification2.1 PSG Susan Owen Page 6 – section on learning from medication errors added Page 9 - Updated to reflect DatixWeb as system forreporting incidents Page 10 – guidance on recording incidents in the carerecord added Page 16 – arrangements for reporting to SHA andcommissioners updated Page 17 - RIDDOR reporting updated to reflect newrequirements from April 2012 Page 17 – guidance on reporting to SIRS added Page 24 – arrangements for providing training added Page 25 - Monitoring arrangements updatedJuly 2008June 2009June 2011May 2012Responsibility for distribution of this documentPatient Safety Lead2

CONTENTSNO DESCRIPTION PAGE NO.Part APolicy aims and scopeIntroduction 4Policy Statement 4Scope of Policy 5Part BProcedures for reporting and investigating1 Roles & Staff Responsibilities 72 Reporting and immediate actions 93 Initial service management review and investigations 184 Support for victims, perpetrators, families, carers and staff 225 Implementation and monitoring of action plans 256 Dissemination, and learning lessons from incidents 25Part CTraining and monitoring7 Training in incident reporting and investigation 268 Monitoring statement 26AppendicesI Classification table 27II Flow charts 30III Adverse Incident form 32IV Guidance notes for completing adverse incident form 34V Service Management Review Report template 36VIGuidance on integrated reporting and review on serious casereviews (Working Together to Safeguard Children 2006)39VII RIDDOR- Information /flow chart 43VIII Guidance for senior managers on conducting and inquiry 44IXGuidelines on writing witness statement or report involvingCoroner or PoliceX Forensic Readiness Guidance added 51XI Borough Template for Critical Incident/SUI notification 53483

PART AINTRODUCTION1.1 Oxleas NHS Foundation Trust is committed to providing the highest standard of care for peoplein mental health, learning disability needs and community settings. Patient Safety in the Trustis enhanced by the use of health care processes, activities and working practices that preventor reduce the risk of harm to patients, staff and visitors.The Trust is committed to identifying and learning from all patient safety incidents and otherreportable incidents, and in making improvements in practice based on local and nationalexperience and information derived from the analysis of incidents.This document describes incident management processes and procedures.National regulatory bodies and best practice guidance provide the Trust with a framework forthe reporting, management, investigation and learning from incidents.The key drivers are:• Equality and excellence – Liberating the NHS (DoH July 2010)• Serious Incident• National Health Service Litigation Authority risk management standards (April 2008)• National Patient Safety Agency Seven Steps to Patient Safety• Independent Investigations of Serious Patient Safety Incidents in Mental Health ServicesGood Practice Guidance(NPSA Feb 2008)• Healthcare Commission core standards• Health and Safety Executive (HSE)• Department of Health guidance ’An Organisation with Memory (2000), ‘Doing Less Harm’(2001), and ‘Building a Safer NHS for Patients (2001)• ‘Being Open’ (2006)• Strategic Health Authority (NHS London) Guidance• Learning from investigations (Healthcare Commission, 2008)• London Child Protection Procedures (London Safe-guarding Children Board, 2007)• Working together to safeguard children 2010• National Framework for reporting and learning from serious incidents requiringinvestigation 2010• Checklist for reporting, managing and investigating information governance seriousuntoward incidents. Doh Jan 2010POLICY STATEMENTThe Trust has a responsibility to provide safe and effective services and promotes a safety consciousculture. It encourages all staff to report any patient, staff or visitor safety incident in order that; safetyissues are identified, investigation procedures are initiated and that learning from experience can takeplace. The Trust accepts that human errors occur, and does not seek to place unfair blame onindividuals. The methodology for investigation adopted by the Trust focuses on improving systemsand processes to prevent human error.However, there may be circumstances when disciplinary action will be in accordance with the TrustDisciplinary Policy. Disciplinary proceedings might be considered appropriate where there aregrounds for believing an employee:• has acted criminally or maliciously• is responsible for professional malpractice4

• has acted with gross misconduct• has a record of significant repetition of mistakes• or has not reported errors or violationsRAISING A MATTER OF CONCERN (WHISTLE BLOWING) PROCEDUREThe Trust promotes a culture of openness and transparency whereby staff and other workers areencouraged to raise a concern in confidence. The procedure applies to all employees of the Trust andalso contractors providing services, agency workers, home workers, and trainees on vocational andwork experience schemes, bank staff and those who hold honorary contracts. The procedure isavailable on the trust intranet at http://www.oxleasintranet.nhs.uk/library/1359.pdfSCOPE OF THE POLICYThe following adverse events fall within the scope of this policy:Adverse Incident/accident – Any unplanned and uncontrolled event which led to or could have led toloss to patient, member of staff or member of the public.Serious Incidents for investigation – Something out of the ordinary or unexpected, with the potentialto cause harm and /or likely to attract public and media interest that occurs on NHS premises or in theprovision of an NHS or a commissioned service. Please see appendix 11 for the appropriate boroughtemplate for the process for critical incident/SUI notification.Near miss - any unintended or unexpected incident that was prevented by some form of interventionand so resulted in no harm but without the intervention may have resulted in harm to one or morepersonsSecurity incident - thefts, deliberate damage to property etc.Never Event - The NPSA definition of a ‘Never Event’ is: A serious, largely preventable patient safetyincident that should not occur if the available preventative measures have been implemented byhealthcare providers.Reportable injuries, Diseases or Dangerous Occurrences (RIDDOR) – these are defined inSchedules1, 2 and 3 of the RIDDOR (1995) and are detailed in the Appendix VIII e.g. fractures, acuteillness requiring medical treatment, loss of sight of an eye, act of violence against staff resulting inthem being off work for more than 3 days.It applies to all incidents occurring in the previous 6 months that;a) occur on Trust premises or,b) occur off Trust premises but involve persons employed by the Trust whilst on Trust business or,c) involve any patient receiving care from the Trust – including joint mental health services withlocal authorities or,d) are unexpected deaths, apparent suicides, and homicides by former patients within 6 monthsof discharge.Safeguarding ChildrenWhere there is harm or potential harm to a child or young person, the incident management policyguidelines must be considered together with Safeguarding Children Policy and procedures.In addition, if the incident raises a concern that a member of staff has behaved in a way that has, ormay, harm a child or which indicates that s/he is unsuitable to work with children, this must be reported5

to the Senior Officer within HR who deals with such allegations. Advice can be sought from the TrustLead for Safeguarding children.Child Death ReviewFrom April 1 st 2008 Local Safeguarding Children Boards (LSCB) have responsibility for followinginterrelated processes for reviewing child deaths, (either of which can trigger a Serious Case Review).These processes will ensure that all child deaths are reviewed by a panel and that unexpected deathsare followed up by a rapid response team. Further details can be found as Appendix VI.Where a child dies unexpectedly, staff who have been working with the child or the family may becontacted by a member of the rapid response team and asked to provide relevant information.All child deaths need to be reported to the lead for Health within each of the LSCBs. Where staffbecome aware of a child death they should report this to ensure that the appropriate review processhas been put in place. Staff can contact the Trust’s Named Professionals for Safeguarding Childrenand share information about the child death; this will be passed onto the appropriate health lead withinthe LSCB.Safeguarding AdultsThe incident policy guidelines should also be read in conjunction with multi-agency adult protectionmanuals. The local authority is the lead agency for conducting the investigations and the IncidentManager /directorate lead will be required to liaise with the relevant borough lead. Normally, theinvestigation of any incidents involving Oxleas staff will proceed in accordance with Oxleas’ ownpolicies and procedures. The local authority borough leads may undertake an independentinvestigation if the circumstances warrant.Staff should always refer to the Oxleas Safeguarding procedures and local multi-agencyprocedures which can be accessed on the Trust intranet and which include details of localleads.Medication errorsMedication errors should be reported via the trust incident reporting system. Details of medicationerrors are collected via Datix and these are reviewed by the pharmacy lead for medication safety, whoreceives these routinely via DatixWeb. Where themes emerge or there are lessons that can be learnt,information related to the errors reported and how these can be avoided in future are shared in themost appropriate way. Individual strategies are agreed at the Medicines Management Committeeand/or Patient Safety Group and dissemination may for example be through the pharmacy newsletter,junior doctor induction or targeted presentations to nursing staff.6

PART BThe procedural guidance is divided into six key areas:1. Roles and Responsibilities2. Reporting and immediate actions3. Initial service management reviews and investigations4. Support for victims, perpetrators, families, carers and staff5. Implementation and monitoring of action plans6. Dissemination and learning lessons from incidents1. ROLES AND RESPONSIBILITIESAll Staff• to have an awareness of their requirements to report incidents and comply with therequirements of this policy.Chief Executive• agrees the level of investigation to take place for serious incidents (Level 4 and 5)• appoints Chair and Panel for all Level 5 inquiries and agrees terms of reference• ensures that Board of Director’s Inquiry Reports into serious incidents are presented to theBoard and that they are accompanied by an action plan• provides final sign off and approval of completed Level 4 reportsDirector of Nursing and Governance• accountable director for patient safety• chairs the Patient safety group and reviews all serious incidents on a weekly basis with thePatient Safety Lead.• advises the Chief Executive on the outcome of the panel’s discussions in relation to initialservice management reviewsClinical Lead for Patient Safety• to coordinate trust wide Embedding the Learning from all serious incidents.• to provide quarterly Embedding the Learning newsletters and training events.• to provide medical advice to board level inquiries and when required directorate inquiries.Patient Safety Lead• provides advice and support to directorate teams.• coordinates reviews of serious incidents• co-ordinates and oversees the management and investigation of serious incidents includingthe Trust inquiries.• supports systems of learning from serious incidents in order to reduce the risk.• ensures that reports submitted to the Coroner’s Office are clear and factually accurate.• ensures that staff are supported in Coroner’s inquest proceedings and other formal inquiries• ensures that arrangements are in place for professional and legal representation to Coronersinquests.• maintains a status report on all serious incidents7

Head of Safeguarding Children and Lead Named Nurseo coordinate the Individual Management Review (IMR) for Serious Case ReviewsHead of Compliance• co-ordinates and oversees the reporting of incidents on STEIS and DatixWeb.Service Directors• ensures oversight of incident reporting within the directorate and the implementation of anyimmediate actions that are required.• ensures that an adequate level of investigation is conducted within the directorate• reports incidents to the Host and Commissioning PCT’s within 24 hours where appropriate• maintains contact with families following serious incidents and keeps them informed andinvolved of progress• ensures that initial service management review reports are verified within the specifiedtimescale of 3 days• ensures directorate investigation into serious incidents are conducted and completed within60 working days• Responsible for drafting an action plan and ensuring that recommendations are implementedwithin the timeframe and reported to the Patient safety group and Board of DirectorsService Managers• ensures that team managers have appropriate knowledge, skills and experience to undertakeinitial investigations and formulate reports• ensures that an appropriate investigation is carried out according to the grading of theincident and that completed forms are forwarded to the Patient Safety Lead within thespecified time scale.• ensures incident reporting is included in the local induction for all new staffTeam Managers / ward managers• ensures staff awareness of reportable incidents, including near misses.• ensures that patients, carers/relatives are informed about incidents and supported, asrequired.• supports the completion of initial service management reviews• ensures the incident reporting procedure training is delivered as part of the local inductionarrangements for all staff.• ensures incident forms and reports are completed within the specified time scale.Head of Communications• manages all media relations (see note below)• is responsible, in liaison with the Chief Executive and other relevant Directors, to managemultiple enquiries from the public.• the communications office and telephone number will be used as the communication centreand hot line.• under the direction of the Head of Communications, extra staff will be allocated to respond tocalls. Calls received and advice given will be logged.Note: Staff may receive enquiries from the media. Individual members of staff should notprovide any initial comment but should refer the matter to the communications department atPinewood House on 01322 625754. If a media inquiry is received out of hours, the directoron call will be contacted on 01322 294300. The communications team will respond on behalfof the trust or support the member of staff to take part in a media interview.8

If the media is involved, the communications team will ensure, where possible, all personsaffected by or involved in the incident are informed. This includes client, relatives, carers andstaff.1.2 Committee responsibilitiesBoard of Directors• receive briefings on all serious incidents that may require a Board of Director’s Inquiry• commission Board of Director’s Inquiries and approve Panel membership to include; a nonexecutive director, a governor, a medical representative, a nursing representative and othersas appropriate• receive Board of Director’s Inquiry reports and recommendations• agree actions plans arising from Board of Director’s inquiry report recommendationsThe Governance Board• has delegated authority for the management of risk and receives regular updates and anannual report on the Management of Incidents.• provides assurance to the Board that incidents, complaints and claims are managed inaccordance with regulation and Healthcare Commission core standards.• may commission investigations for any purpose within it’s remitSerious incidents for investigationThe Patient safety lead meets weekly with the Clinical Lead for Patient Safety and the Director ofNursing and Governance to examine service management review reports and recommends theappropriate level of investigation/ further actions• ensures investigations are progressed in a timely manner• maintains a record of discussions and decisions of the panel• monitors the serious incident status reportPatient Safety Group• receives quarterly trend analysis• monitors progress on level 4 and level 5 incidents from directorate representatives• identifies risks arising from incident analysis and serious incidents investigations• may commission investigations related to incident trends• ensures that lessons are learned from untoward incidents• reviews the reports and recommendations for National Confidential Enquiries, and otherrelevant national guidance, for example Healthcare Commission reviewsDirectorate Patient safety group• responsible for supporting systems and processes for learning from incidents• monitor the implementation of action plans arising from investigations• may commission local investigations into low level incidents and incident trends• ensure that that lessons are learned locally and improvements madeThe Safeguarding Children Committee• review the lessons learned identified from serious care reviews.Directorate Patient safety group• responsible for supporting systems and processes for learning from incidents• monitor the implementation of action plans arising from investigations• may commission local investigations into low level incidents and incident trends• ensure that that lessons are learned locally and improvements made9

2 REPORTING AND IMMEDIATE ACTION2.1 Reporting an incidentAll incidents should be reported using DatixWeb, the on-line incident reporting system. Staff canaccess DatixWeb via an icon on all trust computers. The hyperlink to the form ishttp://ox01datix.oxleas.nhs.uk/datix/live/index.phpHow to complete the formThe form is simple to use and structured in a way whereby content of a field is determined by theselections made in previous fields. All fields with a red star are mandatory. The form contains fieldswith dropdown options from which a selection should be made. There are prompts and guidancewithin the form, as well as links to relevant trust policies. Section 1 – People involved: regardless of whether or not they were harmed as a result of theincident Section 2 – Reporter: enter your name, job title, place of work etc Section 3 - Incident details: ie the date, time and factual description of what happened, whataction you took Section 4 – Team or Department Reporting Incident: the directorate, service and teamreporting the incident Section 5 - Incidents classification: The selection in the first box “Type” will determine theavailable choice under “Category” which will then determine the available choice under “Subcategory” Section 6 - Incident severity and result: please refer to the incident classification chart; thelink to this is found on the left hand side of the form Section 7 - Your manager: enter the details of your manager; they will receive a copy of theincident via email.If you have a query about the system or any problems completing the form please contact the PatientSafety Team at Pinewood House on 01322 621012 or via email at incidents@oxleas.nhs.ukAll level 4 or 5 incidents should be escalated through the line management route and notifiedto the Patient Safety Team at Pinewood House prior to submitting the incident report.What to do if DatixWeb is unavailable - manual reportingIn the event of DatixWeb being unavailable, the manual incident report form (Appendix III and IV)should be downloaded from the Trust Intranet (http://www.oxleasintranet.nhs.uk/library/7632.doc)completed electronically and submitted to incidents@oxleas.nhs.uk via email. When submitting theform, the email subject heading must include the level of the incident and initials of the individualaffected by the incident. The line manager should be copied in to the email with the incident attached.If e-mail is unavailable, then fax or internal mail should be used.Incident reporting and the clinical care recordAny incident concerning a patient should be noted in detail in the patient's care record. However, theincident report form and details of the investigation process, including coroner's inquires should not bekept in the clinical record as this could contain information third party information, or information whichhas been given in confidence and not relevant to the patient’s on-going care and treatment.10

2.2 Procedures and timescales for the immediate management of incidentsAlso see flowchart at Appendix IILEVEL 1, 2 and 3 INCIDENTSLevel 1Immediate Within 24 Hours Within 3 daysInform the person-in-charge/relevant seniorstaffAny immediate action to preventreoccurrence and provide treatment.Review plan of care , where appropriateDocument in progress notesReport incident via DatixWebStaff member reporting the incident informsall relevant managersCarry out any immediate actions to ensuresafetyInform service user/carer of the incident ifappropriate (e.g. medication error)Service Manager ensures appropriateaction taken and checks classificationLevel 2Inform the person-in-charge/relevant seniorstaffTake any immediate action to preventreoccurrence, provide treatment includingfirst aidCarry out any immediate actions to ensuresafetyas Level 1 above plusIf staff member involved (Refer to guidancenotes inside the Accident Book andRIDDOR flow chart – Appendix VII)assess the need to attend occupationalhealth departmententer incident in the local accident bookStaff member reporting the incident informsall relevant managersLevel 3Inform the person-in-charge/relevant seniorstaffAny immediate action to preventreoccurrence, assess and provide treatmentincluding first aid/ or attendance at A&EAs Level 2 plusStaff member reporting the incident informsService Managerrefer to medical staff for further assessmentand treatmentIf the Patient Safety Teams request aservice manager review report this is to beforwarded to the Patient Safety Team bythe relevant managerFor staff incidents:11

Immediate Within 24 Hours Within 3 daysCarry out any immediate actions to ensuresafetyPlus:Inform Service Managerimmediately or as soon as practicalnotify Responsible Medical Officer/Directorate Lead Clinician as soon aspracticableInform service user/carer of incident andother relevant parties as required (e.g. PCTCommissioner and regulatory agencies).report incident to Police, if required (refer toPolice Liaison Policy and Prevention &Management of Violence and AggressionPolicy)Report incident via DatixWebIf staff member involved: as level 2 plusenter incident in the local accident bookAssess the need to attend occupationalhealth department/Local hospitalAdvise staff to record the incident underRIDDOR regulations, if required (Refer toRIDDOR flow chart – Appendix VII).Forward copy of RIDDOR from to thePatient Safety Team.forward copy of incident report tooccupational health department within 72hoursarrange a risk assessment of all significanthazards involving staffLEVEL 4 AND 5 INCIDENTSLevel 4and 5NHSLondongrade 1Immediate Within 24 Hours Within 3 daysAs Level 1, 2 and 3 plusrefer to medical staff for urgent assessmentand treatment at the A&E local hospital andinform Responsible Medical Officer (RMO)and Directorate Lead Clinician immediatelyInform Service Director and Director oncall immediatelyAs level 3arrange post incident supportThe Service Director will ensure that theincident is investigated and an initial servicemanagement review report is completedwithin 72 hours and copy sent to PatientSafety Team lead who will forward copies tothe appropriate parties.12

Immediate Within 24 Hours Within 3 daysService manager:Ensure immediate review of the situation toensure safety, such as ligature pointremoval/any urgent changes to policies orproceduresInform Patient Safety Team by telephoneand report incident via DatixWebFor staff incidents:Assess the need to attend occupationalhealth departmentAdvise staff to record the incident underRIDDOR regulations, if required (Refer toRIDDOR flow chart – Appendix VII). Forwardcopy of RIDDOR from to the Patient SafetyTeam.The Service Director/or Director on callensures that the following personnel arenotified immediately or as soon aspracticable• Director of Nursing & Governance• Medical Director/Clinical Director• Director of Human Resources &Development (in case of staff)• Patient safety lead• Head of communication (in case ofmedia interest)arrange a risk assessment of all significanthazards involving staff.If agreed with the Chief Executive, inform theStrategic Health Authority by reporting onSTEIS.All relevant physical, scientific anddocumentary evidence must be obtained andpreserved13

HOMICIDEHomicideNHSLondongrade 2Immediate Within 24 Hours Within 3 daysAs Level 5 PLUSContact the police and agree who will makethe initial contact with the victim’s family.Similarly with respect to the suspectedperpetrator’s family.All relevant physical, scientific anddocumentary evidence must be obtainedand preserved as described in theMemorandum of Understanding between theACPO, the Department of Health and theHSEThe Chief Executive (or executive Boardmember) will appoint a senior manager/clinician to undertake the internal servicemanagement reviewIdentify whether the injured party/perpetrator is a vulnerable adult or child andact in accordance with the protection ofvulnerable adults or local safeguardingchildren policies.Identify witnesses such as staff and serviceusers and other involved people to ensurethey receive any immediate support neededAs Level 5 PLUSAn initial service management review reportis completed within 72 hours by anindividual/ oversight group appointed by theChief Executive. The oversight group willinvolve key stakeholders including the SHA.If agreed with the Chief Executive, informthe Strategic Health Authority by reportingon STEIS.Following the local incident reportingprotocol, report to the SHA, PCT and MentalHealth Act Commission if a detained patientis involved.NEVER EVENTSNeverevents“Never Events” are serious, largelypreventable patient safety incidents thatshould not occur if the available preventativemeasures have been implemented.All “Never Events” should be reported via theprocedures described above.The core list of never events is as follows:1. Wrong site surgery (existing)2. Wrong implant/prosthesis (new)3. Retained foreign object post-operation (existing)4. Wrongly prepared high-risk injectable medication (new)5. Maladministration of potassium-containing solutions (modified)14

Staff should not report patient safetyincidents directly to the NRLS; this willbe undertaken by the Patient SafetyDepartmentFor more information, please see; NeverEvents - NRLS6. Wrong route administration of chemotherapy (existing)7. Wrong route administration of oral/enteral treatment (new)8. Intravenous administration of epidural medication (new)9. Maladministration of Insulin (new)10. Overdose of midazolam during conscious sedation (new)11. Opioid overdose of an opioid-naïve patient (new)12. Inappropriate administration of daily oral methotrexate (new)13. Suicide using non-collapsible rails (existing)14. Escape of a transferred prisoner (existing)15. Falls from unrestricted windows (new)16. Entrapment in bedrails (new)17. Transfusion of ABO-incompatible blood components (new)18. Transplantation of ABO or HLA-incompatible Organs (new)19. Misplaced naso- or oro-gastric tubes (modified)20. Wrong gas administered (new)21. Failure to monitor and respond to oxygen saturation (new)22. Air embolism (new)23. Misidentification of patients (new)24. Severe scalding of patients (new)25. Maternal death due to post partum haemorrhage after elective Caesarean section(modified)Natural Cause deathsAll deaths (whatever their suspected cause) are classified as an adverse incident or serious incident in the first instance and should reported within 24hours. A 72 hour service review management report should be submitted to the Service Director/Service Manager. The Patient Safety Lead will thenliaise with the Director of Nursing and Governance, Clinical Lead for Patient Safety, relevant Service Director and the Chief Executive to decide whatfurther action is required (e.g. formal Board of Director’s Inquiry or further management action).• When any serious incidents such as unexpected deaths, homicides, serious outbreak of infection occurs an initial internal service managementreview should take place and reported within 72 hours.• Internal investigation into serious incidents will be conducted using Root Cause Analysis methodology. This process would normally be completedwithin 90 days.15

2.3 Reporting to external agenciesCoroner and Rule 43 Coroners’ RuleAdverse events involving the sudden and unexpected death of a patient should be reported to theCoroner by the doctor certifying the death. A Coroners inquest is an inquiry into who has died andhow, when and where the death occurred. An Inquest does not determine blame and the verdict willnot identify someone as having criminal or civil liability. All communication with the Coroners office isvia the Patient Safety Lead.The Rule 43 of the Coroners’ Rules gives the Coroner the power to make reports to a person or anorganisation where the Coroner believes actions needs to be taken to prevent future deaths. The ideais to ensure that lessons are learnt especially when the State is involved with it’s obligation underHuman Rights Act 1998 to protect life.The rule applies to incidents of unexpected deaths and suicide nature, within an in patient setting andincludes clients with informal and formal status.Upon receiving the Coroner’s report, the Trust will:• Acknowledge within 7 days and arrange to report back to the Coroner within 56 days.• Maintain a database of reports and responses to ensure compliance with governancerequirements.• Feedback the response and action plans and any other issues into governance groups withinthe Trust• Ensure an annual review of all rule 43 reports and responses are published to the ExecutiveBoardStrategic Health Authority (NHS London):NHS London has issued guidance to NHS Trusts and PCTs regarding the reporting of seriousincidents. The guidance does not fully apply to NHS Foundation Trusts, who are required to agreereporting arrangements with local commissioners. The Trust will report the following to NHS Londonvia Strategic Executive Information System (STEIS). The Patient Safety Team are responsible foruploading incidents to STEIS.• Homicides• Any other serious incident as agreed by the Chief Executive. The Patient Safety Lead willmeet with the Chief Executive weekly to review the register of serious incidents and identifythose that will be notified to the Strategic Health Authority.The Strategic Health Authorities may choose to commission an independent investigation in thefollowing circumstances:a. When a homicide has been committed by a person who is, or has been, under the care, thatis subject to regular or enhanced care programme approach, of specialist mental healthservices in the six months prior to the event.b. When it is necessary to comply with the State’s obligation under Article 2 of the EuropeanConvention on Human Rights. Whenever a State agent is, or may be, responsible for adeath or where the victim sustains life threatening injuries, there is an obligation on theState to carry out an effective investigation. This means that the investigation should beindependent, reasonably prompt, provide a sufficient element of public scrutiny and involvethe next of kin to an appropriate extent.c. Where the SHA determines that a serious patient safety incident warrants an independentinvestigation, for example if there is concern that an event may represent significantsystemic service failure, such as a cluster of suicides.16

Reporting to commissionersSerious incidents are reported to commissioners as and when they occur by nominated directorateleads. Standard templates for submitting these reports and contact details are provided at Appendix11.Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) - Under the Reporting ofinjuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR), the Trust has a legalduty to notify the Health and Safety Executive (HSE) with details of certain incidents that occur in thecourse of work activities. The types of incident reportable through this process are numerous butserious injuries and dangerous occurrences must be reported to the HSE immediately, with a ten daylimit on reporting workplace injuries which have resulted in staff absence of over seven days. Theperson affected by the accident or their line manager is responsible for submitting the report.NHS Litigation Authority - Incidents where negligence may have been a factor, and that potentiallycould lead a large value claim (ie damages of over £250,000) must be reported to the NHSLA as soonas possible, usually before a claim is made. The Legal Service Manager is responsible for informingthe NHSLA.Security Management Service – all security incidents are reported to the LSMS who escalates thosemeeting the criteria to SIRS.National Reporting and Learning System (NRLS) – The NRLS was established to ensure that thehealth service learns from patient safety incidents. The Trust provides summary data to the NationalReporting and Learning System (NRLS) via a monthly upload from Datix to the NRLS. The PatientSafety Team is responsible for processing the upload.Professional Regulatory Bodies (e.g. NMC, GMC etc) - Suspected or proven misconduct involvingnursing staff, allied professional or medical staff will be reported to relevant professional body, usuallyby Human Resources. In the case of a breech in terms of conditions then Monitor would be contactedby the Trust Secretary on behalf of the BoardMedicines and Healthcare Products Regulatory Agency - Adverse events and near missesinvolving any suspected adverse reactions to medicine will be reported to MHRA. The practitionerwho has identified the reaction should complete and return a ‘yellow card’. Staff should seek advicefrom a doctor or pharmacist if they wish to discuss Adverse Drug Reaction. Where an item of medicalequipment has caused harm or the potential for harm to patients, the MHRA must be notified of anymodification or repairs made. The equipment should be removed and quarantined in a safe area.Environmental Health - The Trust reports all incidents concerning food and environmental safety.The Health and Safety Team is responsible for this.Fire Safety Authority - The Trust reports all serious untoward incidents involving fire. The Health andSafety Team is responsible for this.Health Protection Agency - Under certain circumstances there is a requirement to report HealthcareAssociated Infections (HCAIs) to the Health Protection Agency (HPA). This is covered in detail in theReporting HCAIs to the HPA Policy. The Lead Nurse Infection Control is responsible for this.Mental Health Act Commission - The death of a service user under Section or a homicide committedby a service user under section. The Head of Mental Health Legislation is responsible for this.17

3 INITIAL SERVICE MANAGEMENT REVIEW AND INVESTIGATIONS3.1 Service Management ReviewAn Initial Service Management Review must be completed for all Level 4, 5 and Homicide incidentsand sent to incidents@oxleas.nhs.uk within 72 hours. For the purposes of grading of incidents amanagement report may be requested for level 3 incidents. The report pro forma is attached atAppendix V. An internal investigation oversight group may be established in the case of the mostserious incidents (e.g. Homicide) to direct the initial review. Key stakeholders should be involved inthe oversight group including the Strategic Health Authority (refer also to the DH/ACPO/HSE/MOU).3.2 InvestigationThe internal investigation should be completed as soon as possible after the event with a deadline of60 working days from the incident date. It is important that this process takes place promptly so thatany changes needed to policy or practice to enhance patient safety can be made and the independentinvestigation, if there is to be one, is not delayed. This process is a necessary precursor to theindependent investigation.Depending on the nature of the incident, there may be other relevant policies such as vulnerable adultand safe guarding children policies and procedures that need to be taken into account.The Chief Executive and the Director of Nursing and Governance will identify senior individuals tocarry out a Board of Director’s Inquiry and decide whether any other agencies or organisations need tobe included. The Board of Director’s Inquiry panel will be selected in relation to the nature of theincident and will include some or all of the following: a non executive director, a governor, a medicalrepresentative, a senior nursing representative (or other appropriate discipline), and executive teammember, independent advisor.The terms of reference must include:• Circumstances surrounding the incident• Appropriateness and adequacy of care and treatment• Consideration to the involvement of family and or carers.• To produce a report on its findings making recommendations on the best course of action tobe taken to remedy any unsatisfactory matters and to ensure as far as possible, no similarincident is repeated in the futureA systematic approach to investigation, such as Root Cause Analysis should be used in allinvestigations.Root cause analysis (RCA) is a technique that looks beyond the individuals concerned and seeks tounderstand the underlying system features and environmental context in which the incident happened.Retrospective and multidisciplinary in approach, RCA is designed to identify the sequence of eventsthat led to the incident. This allows the underlying causes of the incident to emerge so thatorganisations can learn and put remedial action in place. A root cause is the cause or causes that ifaddressed will prevent or minimise the chance of a similar incident recurring in the future.3.3 The internal investigation should follow the process described below:Convene the investigation teamThe core investigation team should ideally comprise people of appropriate seniority, objectivity andauthority, and be trained in the RCA/investigation techniques.Gather information18

One of the primary aims of the investigation team is to collect evidence. There is a vast array ofinformation and data surrounding any incident and this is particularly true for mental health incidents,which typically have relevant history that often spans years. The types of information required mayinclude the following, but this is not an exhaustive list:• healthcare records;• records of interviews with staff;• relevant results and diagnostic aids;• policies and protocols in protocols in operation at the time of the incident;• relevant integrated care pathways where available;• the initial incident report;• the list of key staff involved and written reports from staff.Interviews should be held to find out what happened and how and why it happened. The interviewprocess should be supportive and non-judgemental and be conducted in private. It is suggested thatthe cognitive interview approach is used for this purpose. Depending on where the incident took place,a site visit may help the team to establish whether the physical environment was a contributory factorin the incident. It can offer an insight into factors such as the line of sight between a member of staffand the service user affected by the incident or the positioning of equipment.Map eventsOnce the basic data about the incident have been collected, a facilitator will work with staff associatedwith the incident to piece together the chain of events. This can be a valuable forum for developingideas about how to adapt the system to prevent repeat incidents. Involving staff in this mappingexercise has been found to have a significant positive impact on the way a team works and engendersa sense of contributing to workable solutions. A tabular timeline or chronology is a useful way ofproviding this information as an appendix to the report.Identify problemsOnce information about the incident has been gathered, the problems in care and service deliveryshould be identified and prioritised. This enables analysis of aspects of the incident in an appropriateorder.Analyse informationThe problems in care and service delivery are then analysed to determine their underlying causes(contributory factors and root causes) and the lessons that can be learnt. The investigation teamshould consider the circumstances that individuals faced at the time and the evidence the team hadbefore it, and it should not be biased by either the outcome or hindsight.A number of tools are available and the following have been shown to work well across a number ofdifferent healthcare settings:• brainstorming;• change analysis;• nominal group techniques;• five whys techniques;• fishbone diagrams, based on the NPSA list of contributory factors:- patient factors;19

- individual factors;- task factors;- communication factors;- team and social factors;- education and training factors;- equipment and resources factors;- working conditions and environmental factors;- organisation and strategic factors.Recommend solutionsRetrospective Barrier Analysis is the recommended tool to assess the effectiveness of exitingbarriers/controls and to develop additional and/or alternative solutions.A barrier is a defence or control measure to prevent harm to vulnerable or valuable objects (people,buildings, organisational reputation and the wider community). There are four main barriers inhealthcare: physical barriers, natural barriers, human action barriers and administrative barriers. Thefact that an incident has taken place means that one or more of the barriers have not been in place orhave failed. The analysis offers a structured way to visualise the events related to systems failure andcan be used to solve problems or evaluate existing barriers.This stage is designed to identify:• which barriers should have been in place to prevent the incident;• why the barriers failed; how they could be strengthened to prevent future failure;• which other barriers could be used to prevent the incident happening again.In recommending solutions care should be taken to base recommendations on root causes.Write the ReportThe RCA concludes with an investigation report. This needs to be written as soon as possible and in away that is accessible and understandable to all readers.The report should:• be simple and easy to read;• have an executive summary, index and contents page and clear headings;• include the title of the document and state whether it is a draft or the final version;• include the version date, reference initials, document name, computer file path and pagenumber in the footer;• disclose clinical information for which consent has been obtained, or if patientconfidentiality has been breached, this is balanced against public interest as confirmed bylegal advice;• include the evidence of the methodology used for investigation, for example RCA (includetimelines/cause and effect charts, brainstorming/brain writing, nominal group technique,use of a contributory factor framework and fishbone diagrams, five whys and barrieranalysis);• identify root causes and recommendations;20

• ensure that conclusions are evidenced and reasoned, and that recommendations canrealistically be implemented;• include a description of how patients/victims and families have been engaged in theprocess;• include a description of the support provided to patients/victims/families and staff followingthe incident.For further information on the RCA process, tools and templates please refer to the guidance on theNPSA website: www.npsa.nhs.uk4 SUPPORT FOR VICTIMS, PERPETRATORS, FAMILIES, CARERS AND STAFFThe NPSA has issued guidance to the NHS – Being open – communicating patient safety incidentswith patients and their carers. Although this guidance is primarily aimed at communication withpatients (and their families or carers) who have been harmed as a result of an error in their healthcare,the principles of honesty and openness also apply when planning discussions with victims,perpetrators, families and carers.The basic principles underlying this communication are the:• principle of acknowledgement;• principle of truthfulness, timeliness and clarity of communication;• principle of apology.When an incident leading to serious harm or death occurs, the needs of those affected are of primaryconcern to the trust, and those undertaking any investigation. Any contact should be undertaken in arespectful, dignified and compassionate manner, and in a spirit of openness. The service director willtake the lead, and agree with the family who the main family contact will be.Victims and families want to know:• What happened?• Why it happened?• How it happened?• What can be done to stop it from happening again to anyone else?The victim and family should be offered a meeting. The meeting should not take place at the site of theincident and staff involved in the incident should not be required to attend. The meeting should explainwhat support processes have been put in place and how they can be accessed.If victims and their families do not wish to participate in a meeting with the trust then informationshould be put in writing. If contact is initially rejected further attempts should be made to establishcontact and share information. If contact continues to be rejected in the case of homicide, the SHAshould be asked to take over responsibility for victim and family liaison.21

4.1 InformationVictims, families and carers need to have access to information on the investigation, and should:• be made aware, orally and in writing, as soon as possible of the process of the investigationto be held, the rationale for the investigation and the purpose of the investigation (that is, toestablish facts);• have the opportunity to express any concerns;• be consulted on the terms of reference for both internal and independent investigations;• be provided with the terms of reference;• know how they will be able to contribute to the process of investigation, for example by givingevidence;• be given access to findings of any investigation prior to publication and receive a copy of thefinal report and subsequent action plan;• be informed, with reasons, if there is a delay in starting the investigation or in the publicationof the final report;• be offered media advice, should the media make contact.4.2 AdvocacyIn order to ensure that victims and families are able to participate in the investigation process thefollowing potential needs should be considered:• need for independent advocacy – with the requisite skills to work with bereaved andtraumatised individuals;• diversity issues, for example language support, transport issues, disability;• support and assistance in participating in the investigation process;• provision of information;• ongoing support after the incident;• signposting to other organisations that might be able to provide support and information;• support in liaison with other agencies, for example the police.• The cost of providing any of the above could be considered as part of the overall cost of aninvestigation.4.3 CounsellingCounselling may not be an immediate need, but both short-term and longer-term potentialrequirements should be considered. This might include the need to signpost to organisations that canprovide bereavement or post-traumatic stress counselling.22

4.4 Treatment and supportIt is important to make sure that appropriate treatment and support is provided where needed.Decisions about treatment and care should be taken locally on the basis of a thorough, individualisedassessment of need, the evidence base, the client’s wishes and resources available.A copy of the report and action plan and an opportunity for feedback should be provided.If victims and families want a further meeting this should be arranged. Victims and families shouldalso be told how they will be kept up to date regarding the implementation of the action plan.Families should be advised on how they can complain if they disagree with the findings of theinvestigation.4.5 Engaging and supporting staffWhen a serious incident occurs which leads to serious harm or death there can be significant impacton staff who were involved in or who witnessed the incident. Like victims and families, staff will wantto understand what happened, why it happened and what can be done to prevent it happening again.Staff should have the opportunity to access professional advice from their relevant professional bodyor union, staff counselling services and occupational health services.Staff should also be provided with information about the stages of investigation and how they will beexpected to contribute to the process. Make it clear that the investigation itself is entirely separate toany disciplinary process.Support provided should be ongoing and not one-off and will usually be via the line manager, but insome instances (for example, disciplinary issues), provision of support by someone other than theimmediate line manager should be considered. In circumstances where a staff member is required togive a witness statement to the police, the coroners or in a court of law, support will be arranged bythe line manager and the Head of Incidents. If required, the staff member will be given the opportunityto meet with the Trust legal counsel.4.6 Service usersAny incident leading to serious harm or death may have an impact on and implications for otherservice users. If service users have witnessed the incident, appropriate support mechanisms shouldbe put in place: it may be advisable to review risk assessments and care plans to reflect any additionalneeds. If appropriate, service users who witnessed the event should be asked to contribute to theinvestigation process. If this is the case, the outcome of the investigation and the final report should beshared with them.5 Implementation and monitoring of action plansThe Board of Director’s Inquiry reports and draft action plans are presented to the Board at the earliestopportunity after completion. The Service Director will be responsible for drafting the action plan andensuring the recommendations are completed within the timeframe. The Board agree the actions andtimeframe for implementation. The Trust’s Patient safety group receives progress reports from thelocal service representative.An annual incidents management report, summarising incident data, outcomes of inquiries andlessons learned is presented to the Patient Safety Group and Quality Board.23

Directorate investigations reports and action plans will be discussed at the Directorate Patient SafetyGroups. Investigation reports, action plans and progress for level 4 incidents will be reported to thePatient Safety Group.Locally commissioned investigation reports will be discussed at the most appropriate local group, egdirectorate patient safety groups. They will agree local actions and timeframe for implementation.They may delegate responsibility for monitoring the progress of local plans to their critical incidentgroups. Investigation reports, action plans and progress for level 4 incidents will be reported to thePatient Safety Group.6 Dissemination, and Learning Lessons from IncidentsThe Patient safety group will review and monitor progress for all serious incidents to ensure thatactions are taken that prevent re-occurrence and that learning is shared across the Trust.Learning will be promoted by trend analysis, and the finding of National Confidential Enquiries andother national guidance.Lessons learnt from investigations will be disseminated by local governance groups to service teams.Local representatives at the Patient safety group are required to inform local governance groups of therecommendations of National Confidential Enquiries and other national guidance.Learning will also take place through the following Committees:• Safeguarding Children Committee• Safeguarding Adults Group• Infection Prevention and Control Committee• Health and Safety Committee7 TrainingTraining on incident reporting awareness is included as part of the Local Induction. Initial training onDatixWeb is provided by the Patient Safety Team prior to the “go live” date. This is targeted atmanagers responsible for approving incidents, who will then disseminate training to front line staff.Further DatixWeb training will be provided by the Patient Safety Team on an as needed basis and willbe tailored to suit the needs of the team being trained.Arrangements for the delivery of investigation skills training are described in the Mandatory andEssential Skills Training Policy.24

8 Monitoring statementKey elements to bemonitoredHow will the monitoring be carried outFrequencyResponsiblepersonReported toHow will shortfalls beaddressed and lessons learnt?Incident reportingarrangements, includingtimescales for reporting(Section 2)Reporting to externalagencies (Section 2.3)The investigation isappropriate to the severity ofthe incident (Section 3)Concerns raised via whistleblowing are appropriatelyinvestigatedThe trusts Internal Auditors will monitorcompliance as part of the annual InternalAudit Programme, using the followingdocumentation Incident report forms Investigation files Patient Safety Group minutesAnnually Patient Safety Lead Patient Safety Group As part of their review, InternalAudit will make recommendations.Leads for each of theserecommendations will be identifiedand Internal Audit will monitorprogress against implementation.Progress against will be reported tothe PSG.Lessons learnt from incidents(including medication errors)are shared appropriately(Section 6)An Annual Patient Safety Report will beprepared which will identify themes, lessonslearning and record progress against actionplansAnnually Patient Safety Lead Patient Safety GroupQuality BoardAn action plan will be developedand followed up by the PatientSafety Group.Action plans are implementedand followed up (Section 5)TrainingDutiesArrangements for monitoring the completion of investigation skills training is set out in the Mandatory Training PolicyMonitoring of duties is covered in the arrangements set out above25

Type of incident Level 1NegligibleAbsconds / AWOLAccidentsIncidents aregraded by the levelof actual injury /damage sustainedrather than by thepotential for aninjury / damage tooccurAdult protectionAggressionWhere aggressionis staff to patient orstaff to staff pleaseconsult the PatientSafety Team forgradingThreats to abscond andattempted abscondingAny accident with no/(minimal) injuryFailure to shareinformation that avulnerable adult may beat risk from harm orabuseVerbal aggression withno clear intent/ nondirectedPhysical aggressionpushing, shoving andthreats with no injuryChart to now include alltypes of abuse includingsexual, racist orhomophobic abuse,financial etc.Level 2MinorInformal patient fails toreturn from leaveInformal client withpotential risk leaves thewardAccidents resulting inminor injury requiring firstaid within the serviceDelay in implementingsafeguarding proceduresresulting in a failure toprovide protectionVerbal aggressiondirected at personPhysical aggression withno implements usedcausing minor injury.Possession of banneditems.Persistent sexual racisthomophobic ordiscriminatory commentsand /or behaviorRacial abuse directed atperson/sLevel 3ModerateAbscond but not deemedvulnerable suicidal orviolentDetained patient fails toreturn from leaveInformal patient fails toreturn from leave but isdeemed vulnerable.Violent or suicidalAccidents resulting in asignificant injury thatrequires medical attentioni.e. Accident andEmergency referralRIDDOR IncidentsAn event which impactsadversely on a largenumber of patients orstaffHarm to vulnerable adultfollowing a failure toshare information orimplement safeguardingproceduresVerbal aggressiondirected at person /property with intent.Physical aggressionresulting in restraint,injury requiring medicalattention.Use of weapon /implement resulting ininjury.Possession of a weapon.Threat of sexual assault.Threat of assault basedon equalitycharacteristics – eg race,sexual orientation,transgender, disabilityetc.Sexual harassment withphysical contact. Sexualexposure.Level 4MajorAbsconds deemed to bevulnerable, suicidal orviolentDetained patient underrestriction order fails toreturn and is deemedviolent/suicidalAccident resulting ininjury that requires aninpatient stay in a anacute hospital and or anyfractureMismanagement ofpatient care with longterm effectsSignificant harm tovulnerable adult followinga failure to shareinformation or implementsafeguarding proceduresThreat to Kill or Maim,with intent and or historyof physical aggression.Physical assault resultingin serious injury and orhospitalisation.Attempted homicide.Serious sexual assault.Persistent seriousharassment with contactbut no intent to molest.Use ofweapon/implementresulting in injury to staffor patientPersistent seriousharassment with contactbased on equalitycharacteristicsAssault motivated bydiscriminatory attitudes –eg Racist, homophobicLevel 5 / neverEventsCatastrophicRestricted patientsescape from within theperimeter of a mediumsecure unitAbsconding leading tosuicide / homicide,serious harm to others.AWOL leading to suicide/ homicide, serious harmto othersAccident that results ondeath or life threateninginjuriesSerious adult abuse andor neglect which may ormay not cause death of aclientSerious threat with staffand or patient placed inimmediate danger.Homicide / Manslaughter.Rape and very serioussexual assault.Assault of pregnantwoman causing physicaldamage or harm to thechild or womanAssault of a person with adisability with seriousconsequences -eg loss ofmobilityAssault resulting inserious harm wherediscriminatory attitudesare clearly identified asthe causeDeath N/A Expected death fromnatural causes on aninpatient unit.Unexpected death fromnatural causes in thecommunityForm of words forstalking to be includedUnexpected death fromnatural causes within aninpatient unitSuicide in the communityof client known toservices within 12 monthof the incidentDeath related to illicitdrug /alcohol misuse of acurrent service userSuicide of an in patient orsuicide on Trustpremises.Suicide of clientdischarged within 14days from inpatientservicesFalls Resulting in no injury Fall resulting in minorinjury requiring on sitefirst aidFireSetting off fire alarmsaccidental or deliberatewith little or no disruptionSetting off fire alarmsaccidental or deliberateresulting in evacuationand attendance of firebrigadeFall requiring medicalattention i.e. accident andemergency referralFire resulting in minorinjuryFall resulting in injury thatrequires hospitalisationand/or dislocations andfracturesFire resulting insignificant damage toproperty and orsignificant injuryFall causing deathFire resulting in majordamage to propertyresulting in substantialdisruption to services andor death/ life threateninginjuries of an individualThreat of arsonFire resulting in no injuryor damages26

Type of incident Level 1NegligibleDiscrimination onthe basis ofprotectedcharacteristicsunder the EqualityAct (2010):Ethnicity / race /gender /Transgender / civilpartnership /marriage /Religion / sexualorientation / age /Disability /pregnancy /maternityHealth and SafetyHumanResources/staffingInfection ControlIT andCommunicationManagementLoss/Theft ofpersonal/trustpropertyMedication errorsDerogatory comments orbehavior (including theuse of unacceptable/abusive words) based onequality characteristicsRacist or otherdiscriminatory insignia orimagesPornography where thismay impact on others(excluding private use)Reported defect to theinterior/exterior part orparts of the building notresulting in the disruptionto serviceRelease (spillage/gasdischarge) of thesubstance non hazardousto healthShort term low staffinglevel that temporarilyreduces service quality 1dayStaff whose professionalregistration expiredcontinues to practicewithout prior renewingtheir licenseNeedle stick injury/human bite that breaksskinExposure to body fluidsor other sources ofinfection resulting in 3days sicknessAny outbreak of infection(D&V, MRSA)Any diagnosis ofbacteraemia ( MRSA,MSSA, E Coli) in apatientDisruption of the ITsystem (server failure)affecting serviceprovision > 1 dayCost or loss to trust £500£10,000 Personalloss/cost to client, staff,public £100- £5000Error in administration orprescribing with apotential affect on clientIncorrect dosageDelayed and / or omitted(including omissions dueto alcohol and / or drugmisuse) medicationwhere there are anadverse affectsLevel 4MajorAssault motivated bydiscriminatory attitudes –eg racist, homophobicSerious sexual assaultPersistent seriousharassment with contactbased on equalitycharacteristicsHealth and SafetyIncident resulting inpatient or staff injuryrequiring hospitalisationUnsafe staffing level > 5daysNo staff attendingmandatory training on anongoing basisUnregistered staff or staffstruck of from the registercontinues to practiceNeedle stick injury froma patient with a knownblood borne virus (HIV,Hep B, Hep C)Exposure to body fluidsor other sources ofinfection resulting inserious illnessMRSA, Bacteraemia andC-Diff with infectionSerious Disruption of theIT system affectingservice provision > 5daysCost or loss to trust£10,000 - £40,000Personal cost to client,staff public £5,000 -£10,000Affect on client due toerror in prescribing,administration or dosageAny medication incidentcausing significantirreversible affectsProlonged delayed andomitted medicationwhere there is anadverse affect on thepatientLevel 5 / neverEventsCatastrophicAssault of pregnantwoman causing physicaldamage or harm to thechild or womanAssault of a person with adisability with seriousconsequences -eg loss ofmobilityAssault resulting inserious harm wherediscriminatory attitudesare clearly identified asthe causeHealth and Safetyincident resulting in adeath of patient or staffUnsafe staffing level forservice to operateNeedle stick injurycausing recipient tocontact a serious illness(HIV, Hep B)Sudden or unexpecteddeath where evidencemay be related toexposure to any infectionor infectious diseaseCost or loss to trust ofmore than £40,000 puspersonal loss to client,staff, public of more than£10,000Prescribing ,administration or wrongdosage leading to seriousharm or deathto alcohol and / or drugmisuse) medicationwhere there are noadverse affects27

Type of incident Level 1NegligibleLevel 2MinorLevel 3ModerateLevel 4MajorLevel 5 / neverEventsCatastrophicPhysical Health(including seizures,physical illness andpressure ulcer)include refusingappointmentEnvironmentSelf neglectSafeguardingChildren and youngpeople (includesunborn babythrough to 18 thbirthday)Security incidentsClient presents withunexplained minor injury,e.g. bruisingFailure to shareinformation appropriatelythat a child may be atrisk from harm, or a childbeing at risk of harmeither whilst on trustpremises or from anindividual under the directcare of the Trust, withoutresultant harm beingsuffered by a childVisit by a child to serviceuser terminatedAdmission of a child aged17 to a bed notspecifically single sexand set aside, or withoutsupport from CAHMSstaffPremises or individualareas found unlockedwith no public accessDefacing property towalls with minimum costto the TrustClient presents withphysical illness requiringtreatment on site.Pressure ulcer gradedlevel 2 or below,suspected initialpresentation of pressureulcerDelay in implementingsafeguarding childrenprocedures resulting infailure to provideprotection/intervention atan early stageChild placed art riskduring a visit to a serviceuserChild in contact withperson who is a risk tochildren whilst underTrusts care/on TrustpremisesPremises or individualareas found unlockedwith public accessDefacing property orwalls with a cost to theTrust of up to £500Client in inpatient settingpresents with physicalillness requiring referralto A and E and / orambulancePressure ulcer gradedlevel 3Harm to a child. Eitherfollowing failure to shareinformation to protect thechild, or occurring whilstthe child or perpetratorwas under the direct careof the trustTrespassing on thegrounds of secure unitsDefacing property orwalls with a cost to theTrust of up to £501 -£20,000Patients who have acardiac arrestPressure sores graded, 4and above (where thepressure ulcer developswithin our services)Significant harm to achild. Either followingfailure to shareinformation to protect thechild, or occurring whilstthe child or perpetratorwas under the direct careof the trustAllegations made againststaff of behaviour thathas harmed, or may haveharmed a childAdmission of a child aged16 or under to an adultwardBreak in / robbery ofcommunity / inpatientservices with staffpresentCost to trust of more than£20,000 and securityincident resulting insuspension or majordisruption of servicesSelf harm /unexpected deathSubstance UseTrust staff enteringsecure sites with novisible IDThreat to self harmAttempted self harm withno injuryFailure to provide urinesample on request –Forensic services onlySuspicion of illicit druguse in inpatient servicesPersonal cost /loss tostaff of up to £100Self harm with minorinjuries requiring first aidand or medical attentionon siteUse of alcohol and / orillicit drugs where clientnot intoxicatedDiscovery of alcohol andor illicit drugs in inpatientservicesPersonal cost /loss tostaff of over £101Self harm requiringmedical attention at A&EClient in possession ofdrugs or alcoholEvidence of alcohol and /or illicit drugs use whereclient is intoxicated orposing risk to self orothersSelf harm resulting inserious injuries.Attempted suicide oractual suicide injuriesOverdose of illicit drugsrequiring medicalintervention.Possession of a largeamount of illicit drugs withintent to supplySelf harm resulting indeathLife threatening situationresulting from use ofillicit drugs and/ oralcoholUse / Misuse ofclinical informationFailure to shareinformation with otheragencies or vice versaLoss of all or part of aclinical recordAccidental deletion ofelectronic recordLetters / reportsincorrectly addressedSuspicion of patient withintent to supply illicitdrugs and / or alcoholwithin in patient servicesUnauthorised access to aclinical recordLoss or stolen recordoutside of Trust premisesWillful destruction ofrecordsWritten or verbal breachof confidentialityBreach of informationsecurity impacting onservice delivery requiringfull investigation.Damage to a servicesreputation/Low key local mediacoverage.Serious breach ofconfidentiality e.g. up to100 people affectedMajor breach ofinformation having trustwide imp[act on servicedelivery and or thereputation of the TrustSerious breach witheither particularsensitivity e.g. sexualhealth details, 1000 orover people affected28

Appendix II29

Appendix IIIIncident report form to be used only in the event of DatixWeb being unavailable. This is available onthe trust Intranet at http://www.oxleasintranet.nhs.uk/library/3370.doc31

Incident Report Form Guidance Notes1. If you see an incident, accident or near miss you have a responsibility to report it.2. Anyone can report an incident and submit this form to the Patient Safety Team at PinewoodHouse.3. You should complete as much of the form as possible including any relevant outcomes. If you thinka box is not relevant, then leave it blank – we will contact you if we need more information.4. Level 1, 2 and 3 reports should be submitted to Pinewood House by the person completing thereport – please copy to your line manager. Reports should be completed and submitted by theend of shift (in-patient teams) or the end of the working day (community teams)5. Incident reporting via email is encouraged. The incident report form can be downloaded from theTrust Intranet, completed electronically and sent to incidents@oxleas.nhs.uk . You should copyyour line manager into the email.6. If you have any queries, please contact the Patient Safety Team at Pinewood House on telephone01322 625700 ext 5804 or email incidents@oxleas.nhs.uk .Additional guidance for reporting Serious IncidentsPlease ensure that all serious incidents (level 4 and 5) are copied to the service manager andservice director. This will be accepted as a management signature by the Patient Safety Team.Please ensure that the incident management report is submitted to the Patient Safety Team withinthree working days.32

Guidance notes for completing adverse incident formAppendix IVThis form should be completed for all adverse incidents, accidents and “near misses.” Thesame form should be used for all incidents, whether they affect service users or staff. It isimportant that all incidents are reported, so that the trust can understand how and whyincidents occur and to use learning to improve service user and staff safety.The form should be completed legibly, using block capitals or type. An electronic version isavailable for staff who are happy to use a computer, and staff are encouraged to use thisoption.Section 1 – who, where, what, whenThis section provides information about when and where the incident occurred. All boxesshould be completed as far as possible, but if the time / location of the incident are notknown, please indicate this on the form.All incidents should have a severity grading. The Incident Management Policy and theClassification Chart provide advice on how incidents should be graded.Section 2 – person(s) affected by the incidentThis section should be used to provide detail on the person or persons affected by theincidents. For incidents where both a service user and a staff member were affected – suchas assaults on staff – both sections 2a and 2b should be completed.For incidents when more than one service user was affected – for example, assault oraggression between service users – a separate form should be completed for each client, soindividual details can be appropriately recorded. The two forms should be securely fastenedtogether before returning to Pinewood House, as it will be treated as a single incident whenentered on the database.For service user incidents (section 2a) it is particularly important that the following fields arecompleted as this will ensure that the details are correctly entered on our database:• Full name – use the name as recorded on RiO• RiO number• Date of birth• Legal statusForms without this information will be returned. Other details – ie age, ethnicity, gender –should be included for monitoring and analysis purposes.For staff incidents (section 2b) please complete the following:• Full name – ie as the staff member is called on email and other trust systems.• Job title33

Section 3 – description of the incidentThis section should describe the incident, including details of any losses, damages andinjuries sustained. For medication errors include details of the medicines. For incidentsinvolving medical devices, include details of the equipment. If events prior to the incidentare relevant, these should also be included. Tick the relevant box if drug or alcohol misusewas a factor in the incident.Only facts should be recorded, and information should be relevant to the incident. Thisinformation must be clear and accurate as it may be referred to later, for example if there isan inquiry or if there is a claim made against the trust.You should also include a description of the action taken to manage the incident and preventre-occurrence and support offered to staff, service user or others if appropriate.Section 4 – action takenPlease tick any of the relevant boxes to indicate the immediate action taken to manage theincidentSection 5 – safeguarding children and adultsIf the incident raises any adult or child safeguarding concerns, this should be indicated in therelevant box, and followed up as per Oxleas polices and multi-agency guidance.Section 6 – details of persons completing the formThis should be completed with the name, telephone number and job title of the personcompleting the form so we can contact you if there are any further queries.Section 7 – senior manager sign offLevel 4 and 5 incidents should be signed off by the senior manager or director.Submitting forms by emailThe incident report form can be downloaded from the Trust Intranet, completed electronicallyand submitted to the Patient Safety Team via email. Staff are encouraged to do this, but thisdoes not preclude staff from completing the form in manuscript.Incident forms should be sent to incidents@oxleas.nhs.uk34

SERIOUS INCIDENTAppendix VPRIVATE AND CONFIDENTIALService Management Review ReportIMPORTANT: Complete the details below and forward within 3 days of the incident to the PatientSafety Team at Pinewood House. Please copy to Service Director and Service Manager.Client DetailsName of client:Date of birth:MHA status:NHS no:Ethnicity(at time of incident)Date of incident:Place of incident:Date of Management Report:Name of Team:Name of Keyworker/ Care co-ordinatorReport compiled by:Job Designation:Signature:35

SummaryPlease complete an introductory summary of what happened in no more than 20 linesBackground information:Name and contact details of client’s nearest relative:Have they been contacted? YES/ NODate Time (24 hour clock)If there was a victim(s) or others involved in this incident please provide name(s) and address(es):List all staff involved in client’s treatment, care and assessmentNames Role Contact detailsStaff on duty:Names Job titles Contact details(indicate if temporary staff)Please list any other agencies involved (e.g. police, probation, prison services, coroners, solicitors)and provide a brief account of their involvement:Date of client’s first contact with Oxleas:Referred by:Date:Date of admission (if inpatient)Psychiatric and medical diagnosis:Medication (please include changes to medication and date of change):Other formulationsSocial circumstances and personal historyCPA Level: Enhanced/ Standard(Key elements of care plan):(you may wish to submit a copy of the care plan with this report)Risk Assessment or Forensic AssessmentDate assessment was last reviewed:Summary:(you may wish to submit a copy of the risk assessment with this report)Admissions history:36

Date of discharge from most recent inpatient stay if applicableto whom (e.g.GP, none)Date of last contact:Type of contact (outpatient/ home visit)With whomJob titleList DNAs and missed contacts:Narrative ChronologyPlease give full details of what happened and where in the pre-ceding 24 hours (minimum for inpatient)and 3 contacts (community client) leading up to and including the incident. Include immediate actionstaken at the time to address the incident (e.g. telephoned for ambulance, who was informed etc).Indicate, client mental state, observations, medication, staff interventions etc. in timeline order. Pleasealso state source of information (i.e. who completed notes in clinical record or gave an account ofthese details). Please give as much factual detail as possible.Time of incident (Use 24 hour clock):Details:Community/ outpatient contact,By whom:Details:Date:Community/ outpatient contact:By whom:Details:Date:Community/ outpatient contact:By whom:Details:Date:Please continue with any other relevant contacts in this case including other agencies (if known).Actions taken:Please describe any immediate actions taken to ensure patient and staff safety and describe supportgiven to those involved following this incident:Staff support:Relative/ carer supportAre there any other details relevant to this incident ?Please continue.37

Appendix VIGuidance on Integrated Reporting and Review Under Trust Incident Policy andStatutory Guidance on Serious Case Reviews (as set out in Working Together toSafeguard Children 2006) Relating to Children up to the Age of Eighteen, and Includingthe Unborn.IntroductionThis guidance clarifies key timescales and interfaces between the Trusts incident investigations andLocal Safeguarding Children Boards (LSCB) Serious Case Review (SCR) processes.NHS Foundation Trusts are statutory partners in LSCBs under section 13 of the Children Act 2004 andhave a duty to co operate.Any incident that is reviewed by a LSCB where the child, their parent, carer or other person directlyconcerned has been involved with a Trust service is also by definition a serious untoward incident(SUI). A child includes any person up to their 18 th birthday.The child concerned may be directly cared for by the Trust through the Child and Adolescent MentalHealth Services (CAMHS) or may be the child of an adult known to one of the Trust’s adult services.Therefore several Trust services may be involved across different directorates, community and inpatient services.The LSCB SCR is a multi-agency review and is therefore dependent on and informed by thechronologies and management reports of the partner agencies involved. The LSCB is expected tomake a decision within a month of notification of an incident on whether the criteria for a SCR are metand report fully to the Commission for Social Care Inspection (CSCI) within five months of beingnotified of the incident.LSCBs manage the process through an SCR sub group that includes relevant child protection Namedor Lead Safeguarding professionals from the Trust and other involved agencies. They will commissionan independent overview that brings together and analyses the findings of reports from partnerorganisations and makes recommendations for future action.Statutory guidance contained in Working Together (2006) directs that individuals completing the SCRmanagement report should not have been directly concerned with the child or family or the immediateline manager of the practitioners involved. It also provides guidance on interviewing staff and terms ofreference (TOR) for agency reviews.If a case does not meet the criteria it may be valuable to conduct individual management reviews oraudit of cases that give rise to concern. In such cases, arrangements should be made to sharerelevant findings with the LSCB SCR panel. This may result in a decision for a full SCR to be carriedout.The attached flowchart shows key timescales, actions and relationships between the Trust and LSCBfor each stage.AimsThis guidance aims to:• Integrate the Trust Reporting Procedures described in the Trust Adverse Incident Policy,Generic Investigation Policy and SCR procedures.• Ensure that activities to investigate, review, report and learn from these incidents arecoordinated where necessary to avoid duplication.38

• Ensure that TOR’s and timescales for the LSCB SCR and Trust SUI Policy, (GenericInvestigation Policy) are met.• Bring together the overall response to the one incident across different Trust services(where more than one service is involved) so it can be viewed as a meaningful whole.Criteria for SCR:• When a child dies (including death by suicide) and abuse or neglect is known orsuspected to be a factor in the death.• Additionally LSCB’s should always consider whether a SCR should be conductedwhere:- A child sustains a potentially life-threatening injury or serious and permanentimpairment of health and development through abuse or neglect; or- a child has been subjected to particularly serious sexual abuse; or- a parent has been murdered and a homicide review is being initiated; or- a child has been killed by a parent with a mental illness; or- the case gives rise to concerns about inter-agency working to protect childrenfrom harm.Any professional may refer such a case to the LSCB if it is believed there are important lessons tobe learned for inter-agency working.ReportThe initial report may be from any internal or external source and includes incidents thathappened some time ago or after a patient is discharged. Some reports may be generated fromthe Trust communications department as a result of news reports.In all cases an Incident form and Level 4/5 Management Report must be completed by the TeamManager and the Trust investigation process triggered. The report stage includes immediateattempts to clarify details of the incident and where and how the Trust is involved. There shouldbe close liaison between the originating service and Patient Safety Team that will convene a‘strategy’ meeting if required.Trust Strategy MeetingThis is an initial planning meeting within 48 hours and no later than a week of the incident beingfirst reported.Aims of the Trust Strategy MeetingTo identify which services are involved and related reporting requirements. This includesidentifying Trust services delivered by staff embedded in other agencies and identifying the role ofother agencies where workers are embedded in Trust services such as borough social services.(Non Trust agencies involved through staff embedded in Trust managed services must be notifiedto the LSCB).Agree scope of investigation and initial TOR. The TOR should include development of an actionplan to implement recommendations made.To join up external and internal processes and ensure a co-ordinated, well communicatedapproach from the outset.39

Each incident will be different and depending on the complexity, services involved and volume ofwork indicated the strategy meeting may need to consider who will do what, how and when, howwork will be co-ordinated and membership and arrangements for a Trust co ordination group ifrequired.Membership of Initial Strategy GroupThe following may need to attend depending on the nature and complexity of the incident:• Clinical and service directors of services involved or their delegates.• Manager/s of service/s currently engaged with clients involved in the incident.• Service manager of the last service/s involved if not currently engaged.• Trust safeguarding children Named professionals.• Director of Nursing and Governance who will decide if Trust communications, claimsand litigation or other representatives are required.Information Management and SharingChronologyWorking Together statutory guidance states that ‘Individual organisations should secure caserecords promptly and begin work quickly to draw up a chronology of involvement with the childand the family’.All material and individual entries, including each in patient entry, should be included in thechronology with particular attention given to any expression of safeguarding or other concerns andinteragency contact. All entries should be included as material that may not appear significantwhen compiling the chronology or within one agency, may become more significant later in theprocess.Chronology entries should be objective and factual and not contain judgement or opinion. Thesource of material, mode of communication, author / sender and recipient should all be clearlystated.Some LSCBs provide electronic ‘chronolators’ to assist in merging chronologies. Where adecision has been taken to hold a full SCR the chronology needs to be shared as soon aspossible so that the LSCB can begin to draw an integrated chronology together. In any case it isgood practice and assists subsequent Trust investigation and review if a comprehensivechronology is compiled as soon after the incident as possible.Report and recommendationsA preliminary draft report and recommendations may need to be shared with the LSCB before thefull Trust process is complete. This recognises the need to share findings with the LSCB and PCTDesignated Professionals so that PCT and LSCB overview reports and recommendations can becompleted within five months of notification.Sharing informationIt is recognised that the full Trust process and Board Level Inquiry may be completed later andcontain some material that will not be shared with the LSBC for example:Material from mental health records of adults / parents or carers of the child or other adult unlessthey have given clear consent for this purpose or it is required to protect a child at risk undersection 47 of the Children Act 1989.40

Where the LSCB TOR includes service involvement with parent, carer or other adult they willconsider how consent will be obtained if required. Trust staff may be asked to request this. Wherea Family Welfare Officer is already involved the LSCB will consult with them regarding obtainingconsent.Material outside the timescale of the TOR for the SCR should not be shared unless it meets thecriteria for sharing under section 47 of the Children Act 1989Where the review does not meet the full criteria for SCR only relevant findings of the Trust reviewneed be shared.The Caldicott Guardian may be contacted for advice.Recommendations and Action PlansThe action plan of the SCR will include SMART (Specific, Measurable, Achievable Realistic andTime-limited) recommendations. This should form an appendix to the report.SPECIFIC with well defined goals stating who should do what when and with what degree ofsuccess MEASURABLE that achieves change that can be measured ACHIEVABLE andAGREED with those who need to make it work RELEVANT to solving the problem identifiedand REALISTIC, possible to achieve TIME SPECIFIC with a time-scale for each stage andfor the overall aim and small enough to handle and big enough to show results.It is better to have fewer SMART actions in a plan than more ill defined and vague ones.Implementing Recommendations and Action PlansImplementing recommendations and action plans and reporting back on action taken to the LSCBand Safeguarding Children Committee (sub group of the Safety management Group) are theoverall responsibility of the relevant senior manager. This process is an integral part of the Trustgovernance cycles for reporting and implementation of recommendations.Some actions may be within the remit of the local services involved and some will need actions ata higher level such as within a directorate as a whole, or within a trust wide system such as HR.These should be escalated within Trust governance structures and also reported through theSafeguarding Children Committee.Service Managers and Service Directors will be responsible for reporting on how learning fromSCRs will be communicated with staff.ReferenceHM Government (2006) Working Together to Safeguard Children: A guide to inter-agency working tosafeguard and promote the welfare of children. TSO41

Appendix VIIRIDDOR INFORMATION/FLOW CHARTR ID D O RT he Reporting of Injuries, D iseases and D angerous O ccurrences R egulations 1995Accide nt occu rs to any person arisin g out of or in co nn ectio nwith w orkIf injured perso n is either o ne o f yo urem plo yees, o r a self-em plo yed perso nw ork ing o n you r prem isesAccide nt resu ltsin eith er death orm a jo r injury*(see list in clu dedin the pad ofappro ved rep ortform s) *in clu din gas a resu lt o fph y sical violenceN o tify theenfo rcingautho rityim m ediately e.g.teleph on e and b eprepared to givebrief details ab ou t-your bu sin ess-th e injuredperso n, an d-th e a ccid entAccide nt(includ ing a n a cto f ph y sicalviolen ce) resultsin non-m ajorinjur y bu t theinju red p erso n isabsen t from w orkor un ab le to dohis/her norm alwork fo r m o retha n three (3 )consecutive da ysin clu d in g a ny no nw ork da y s e.g.Satu rday orSu nday, pu blicho lidayIf injuredperso n is am em ber ofthe p ub licAccide ntresults in eitherdeath , or (bein gtaken to )ho spitalN otify theenforcingautho rityim m ediately e.g.teleph o n e an d beprepared to giv ebrief d etails about- y ou r busin ess- th e injured th eperso n, and- th e a ccid entD angero usO ccurrenceA n incident occursw hich d oes notresu lt in areportable in ju rybu t clearly cou ldhav e d on eIf the da ng ero uso ccurrence isrepo rtable (seelist in clu d ed in th epad of appro vedreport form s)N otify theenforcingautho rityim m ediatelye.g. telep h on eD iseaseY ou are notified by ado ctor that o n e of y ou remploy ees is su fferin gfro m a repo rtablew ork -related d isea se(a fu ll list is in clu d edin the pad o f approvedreport form s)Send co m p letedF2 5 0 8A (appro veddisease rep ortform ) to theen forcing auth orityim m ediatelySend co m p leted for m F 25 0 8 (approv ed accide nt/da ng ero us occurrence repo rt) to the E nforcing A utho ritywithin te n (10 ) d a ysIm p orta n t n o te:W h ere a n em plo yee ha s su ffered a n accid ent at work resu ltin g in a rep orta ble inju ry w hich cau seshis/h er d eath w ithin o ne (1 ) y ear o f the date of that a ccid ent, the em ploy er m u st inform the releva nten forcin g au tho rity in writing o f th e dea th as soo n a s it co m es to h is/h er k no wledg e, wheth er or n ot th ea ccident ha s been rep orted.Partic ulars o f the H e alth an d Safety E nforcing A utho rity fo r yo ur O rg an isatio nIncid ent C o nta ct C entre T elep ho n e 0 8 45 300 9 92 3H ealth a nd Sa fety E xecutive Fax 0 8 45 300 9 92 4C aerph illy B u sin ess ParkC aerph illyW ales C F8 3 3G GR E C O R D SA record on an y reportable d eath, injury, da ng erou s o ccu rrence or ca se of disea se m u st be k ept at the p lace w h ere thew ork to w hich it relates is carried o n or at th e ‘respo n sib le person s’ u su al p lace of bu sin ess. A ny su ch record mu st b ek ept fo r three (3 ) years from th e date o n w hich it wa s m a de.42

Appendix VIIIOXLEAS NHS FOUNDATION TRUST.GUIDELINES FOR SENIOR MANAGERSCONDUCTING AN INTERNAL INQURIY FOLLOWING A SERIOUSINCIDENT LEVEL 4 AND 51. INTRODUCTION1.1 These guidelines have been developed as a framework for senior managers conducting aninternal inquiry as part of the Trust Incident Management Policy & Procedure (SeriousIncident Policy)2. FORMATION OF INVESTIGATION PANEL FOR LEVEL 5 BOARD LEVEL INQUIRY2.1 The Chief Executive is responsible for designating a single individual responsible forleading an investigation into the incident. This individual will subsequently act asChairperson for the Inquiry panel. For all incidents, clinical and non-clinical, this person willbe a senior member of the Trust and will normally be a member of the Executive team2.2 The Chief Executive and the designated individual will have the delegated authority tonominate and establish the Inquiry panel to undertake the investigation.2.3 The Chief Executive will form the inquiry panel who will consider the composition of thepanel taking account of:-The nature of the incident and the apparent circumstancesThe expertise of individuals who may join the panel.The investigative skills of individuals who may join the panel.2.4 The inquiry panel will normally compose of three to five individuals. The panel wouldnormally include a representative from the Executive and Non Executive Team, MedicalProfession, Nursing profession, Governor and the specialty involved in the incident.Generally these individuals would be employed in the Trust but there may be someinstances where external specialist advice may need to be sought eg if there are no otherTrust employees of sufficient seniority in the area/speciality concerned.2.5 The Chief Executive in conjunction with the Service Director will seek advice and guidancefrom other agencies where the incident may necessitate Police investigation or where theincident involves child protection issues to ensure that the internal inquiry does notjeopardize other investigations. This consultation may include the Police, Social Servicesor the Area Child Protection committee.2.6 The inquiry panel will be released from their normal duties as required to ensure they havesufficient time to undertake their role within this procedure. This will be supported by theTrust Board.3. THE FORMATION OF INVESTIGATION PANEL FOR LEVEL 4 DIRECTORATELEVEL INQUIRY3.1 The Chief Executive in conjunction with Director of Nursing and Governance & the ServiceDirector will be responsible for designating a single individual for leading an investigation43

into the incident. This individual will subsequently act as Chairperson for the Inquiry panel.For all incidents, clinical and non-clinical, this person will be a senior member of theDirectorate Management Board. In some cases the Service Director will be responsible forleading the investigation.3.2 The Service Director will have the delegated authority to nominate and establish the Inquirypanel to undertake the investigation.3.3 The Service Director will form the inquiry panel who will consider the composition of thepanel taking account of:-The nature of the incident and the apparent circumstancesThe expertise of individuals who may join the panel.The investigative skills of individuals who may join the panel.3.4 The inquiry panel will normally compose of individuals from the directorate managementboard and would normally include Medical Profession, Nursing profession and the specialtyinvolved in the incident. Generally these individuals would be employed in the Trust butthere may be some instances where external specialist advice may need to be sought eg ifthere are no other Trust employees of sufficient seniority in the area/speciality concerned.3.5 The Service Director in conjunction with Chief Executive/Director of Nursing & Governancewill seek advice and guidance from other agencies where the incident may necessitatePolice investigation or where the incident involves child protection issues to ensure that theinternal inquiry does not jeopardize other investigations. This consultation may include thePolice, Social Services or the Area Child Protection committee.3.6 The inquiry team will be released from their normal duties as required to ensure they havesufficient time to undertake their role within this procedure. This will be supported by theTrust Board.4. THE ROLE OF THE CHAIRPERSON IN THE INTERNAL INQUIRY PANEL4.1 The Chairperson in conjunction with the Patient Safety Lead is responsible for formulatingthe draft terms of reference4.2 The Chairperson will discuss and agree the Draft Terms of reference with the Chiefexecutive prior to the first panel meeting (level 5 inquiry). For level 4 inquiry the designatedindividual will agree the terms of reference with the Service director.4.3 The Chairperson in conjunction with the Patient Safety Lead will allocate roles andresponsibilities within the inquiry team and will co-ordinate the entire process to ensure allnecessary lines of enquiry have been followed up.4.4 The Chairperson will discuss and agree the investigation methodology (usually RCA),terms of reference and timescale for completion of report (usually 45 days) with panelmembers at the onset of the investigation4.5 The Chairperson of the inquiry panel will report back to the Chief Executive at regularintervals.4.6 This guidance will be communicated to the inquiry panel by the Chairperson.44

5. CONTENT OF THE INVESTIGATION5.1 The inquiry panel will interview the people involved in the incident and take statements. Allstatements will be typed and returned to the individual concerned to allow the details to bechecked and for the individual to sign the statement to confirm that all facts are accuratelyrecorded.5.2 Members of staff who are interviewed are entitled to support during the interview process.This will normally/always be from a trade union representative or work colleague.5.3 The members of the inquiry panel have the authority to re-interview individuals if requiredi.e. if additional points come to light during the investigation which require furtherclarification.5.4 The members of the inquiry panel have the right to seek legal advice at any stage of theinvestigation where he/she feels this is appropriate.5.5 Where the Chairperson feels that a legal claim against the Trust may result then legaladvice will be sought via the Legal Services Manager.5.6 If the Chairperson feels that the Police may need to be notified of the incident the matterwill be referred to the Chief Executive. Police involvement, where required, must beactioned at an early stage of the investigation to ensure the inquiry team do not jeopardiseany subsequent police investigation.6. STRUCTURE OF INQUIRY REPORT6.1 The Chairperson in conjunction with the Head of Critical Incidents/panel members isresponsible for co-ordinating the inquiry report which should be structured to include thefollowing sections as proposed by the NPSA good practice guidance• Executive summary• Overview of the incident• Terms of reference• Scope of the inquiry• Involvement and support of the patient, relatives and carers• Chronology of contacts with services• Personal information• Past psychiatric history• Methodology for investigation• Identification of root causes• Findings• Recommendations• Conclusions• Lessons Learnt• Arrangements for shared learning6.2 The Inquiry Report will be submitted to the Chief Executive. Elements of the reportincluding key recommendations may be shared with key Trust committees to ensure thatrecommendations are implemented and the risk of a recurrence of the incident reduced.45

7. MEDIA RELATIONS7.1 The members of the inquiry panel will not normally be expected to respond to any mediacontact. Response will be coordinated by the individual who has been designated by theChief Executive as the Trust media spokesperson for the purpose of this incident.8. ACTION PLAN/LEARNING FROM INVESTIGATIONS8.1 Chair of inquiry panel/Board of Directors and Service directors will agree the process forsigning off the Trust action plans and for implementing the recommendations. Theperformance monitoring arrangements will also be put in place.8.2 Trust should ensure that their own staff are genuinely encouraged in performanceimprovement and this culture should pervade the process and be paid special attention atthe conclusion of an investigation.9. OTHER RELEVANT TRUST POLICIESConsideration of the following Trust Policies and Procedures may be helpful dependant on the natureof the incident.Post Incident support policyBeing Open PolicyDisciplinary PolicyHandling of clinical negligence, personal injury and property claims policy46

Guidelines on writing witness statement or report involving Coroner or PoliceAppendix IXIntroductionThis guide is to help you if you have been asked to provide a report or statement about a patientwhose care you have been involved in. It aims to explain why the Coroner/Trust/ Police needs areport from you and to advise you of what to include.A witness statement is the written version of the oral evidence a witness intends to cite on any issue offact at a trial, inquest or other proceedings.Reason for the RequestStaff may be approached to provide statements and/or reports for any of the following reasons:-Coroners InquestAn inquest is a fact finding inquiry conducted by a coroner, with or without a jury, to establish reliableanswers to four important but limited factual questions;• Who was the deceased? (It is not always easy to identify human remains)• How, when and where did the deceased came by their death?and to establish the particulars required under the Registration Acts to be registeredconcerning the deathWhere a coroner is informed that (1) the body of a person is lying within his district and (2) there isreasonable cause to suspect that the deceased• has died a violent or unnatural death; or• has died a sudden death of which the cause is unknown; or• has died in prison (or certain other places or circumstances)Then, whether or not the cause of death arose within his jurisdiction, the coroner shall as soon aspracticable hold an inquest into the death of the deceased.If the circumstances are such as to necessitate the holding of an inquest, a hearing will be arranged.This will often take place within 3 months, but in many cases may take longer to arrange. Statementswill be requested from those the coroner believes may be able to provide relevant information. Somewitnesses may be called to give evidence at the inquest. Coroners will try to avoid calling witnessesunnecessarily. They are less likely to require the personal attendance of a witness if the writtenstatement is in satisfactory form, providing all the relevant factual information, with dates, and makingclear ‘who did what’.There is no legal right for family to see any other reports or statements prepared for a coroner inadvance of the inquest. However, some coroners will respond positively to requests for advancedisclosure of such documents from families or others, or will provide a summary.If you have been asked to attend Coroners court to give evidence, useful to remember the followingpoints:Court Etiquette• Address a Coroner as ‘Sir’ or if female, ‘Ma-am’• Address a Judge as ‘Your Honour’ or ‘Judge’• All rise when Judge/Coroner enters/leaves the room• Witnesses asked to swear an oath or affirm before giving evidence.• Press can be present throughout the inquests.• At inquests, family members or the deceased’s representative may question the witness, inaddition to the Coroner47

Criminal InvestigationStaff are most likely to be asked to provide evidence to the Police following an incident suspected ofcrime which involved a service user, a visitor or another member of staff.Officers will request statements from directly involved staff very quickly after the incident and evidenceis gathered by interviewing the member of staff. Any interview which not held under caution areclassed as informal and can be held at the Trust premises. The Trust wishes to co-operate as fully aspossible with such investigations and urges staff to make themselves available if requested.If however the Police request an interview with a member of staff under caution, this amounts to aformal interview and it is imperative that advice is obtained. For informal interview it is permissible fora colleague to be present for support, and depending on the nature of the incident, it is sometimesappropriate to have the Trust legal representative present. Each case can be considered on its ownmerits. When a request is forthcoming, this issue should be discussed with the Director or LegalServices Manager.Where health professionals belong to a Defence Union, Trade Union or a professional organisation,they may also wish to consult them or obtain their own legal advice.In all cases it is permissible for members of staff to be given time to gather their thoughts andtherefore defer an interview, to allow the member of staff to access the relevant documentation suchas patient records, or for legal representation to be arranged.Police interviewsFor police interviews the usual procedure is that the Police Officer will have a face to face interviewwith the member of staff and will handwrite the statement on a standard form which the member ofstaff will then be asked to read, check, and make any amendments. The amendments are initialedand the member of staff will then be asked to approve the statement and sign the statement of truth atthe end of each page of the statement.It is imperative that the member of staff is content that the handwritten statement as transcribed by thePolice Officer is a true reflection of what was said in the interview, as this will stand as that member ofstaff’s evidence in any forthcoming criminal trial. The Police are often reluctant to permit copies ofstatements to be kept by the witnesses, but it is permissible to request a copy at the time of signing,on the basis that this will be kept confidential.What to put in your reportDocuments produced during the investigation of an adverse incident are not ‘privileged’. This meansthat in any subsequent legal case, the patient’s legal advisor will be able to obtain them from the Trust.It is important that you remember that a report you make as part of incident reporting system orcomplaint may not remain confidential.You must ensure that you have included:Your Full nameQualifications and brief details of your relevant experienceDetails of the post you hold and your job location ie wardState the time you started and finished your duty on the day(s) in question(see profoma)48

The following ‘‘do’s’’ and ‘’dont’s’’ aims to assist you in preparing your statement.DoPrepare your statement as soon as possible afterthe event by reference to the medical records.Contemporaneous documents are more credible.Make sure you understand the task, if you areunsure about what you are being asked to do,seek guidance from:-Critical Incidents ManagerProfessional or Trade Union Representative(RCN/Unison/MDU)Tell the story. Give a detailed, chronologicalaccount of what you did and why. Give details ofyour thought processes and show you chose onecourse of action above another (i.e. because)Identify others involved in the patient’s care.Assume the reader knows nothing of the facts, norof hospital routines. It may be read by a coroneror jury and therefore needs to provide the laypersonwith relevant information.Be factual (Fact NOT opinion).Include everythingyou can remember that is relevant about theincident and any other relevant factors.Respond within the deadline – contact the personwho has requested the report or statement if thiscauses your problems.Remember that the Coroner/Trust/Police is tryingto establish the truth about what happened, behonest about your involvement, not defensive.Don’tRush the exercise. A statement prepared as arequirement of a serious incident is disclosable.Produce a statement without reference to themedical records.Cover up – even if this means admitting that thestandard of care was not to the standard youwere taught or expect.Stray into another witness’s evidence this willconfuse the picture therefore do NOT attempt to‘second guess’ what others were thinking.Include subjective comments i.e opinions aboutthe patient or others)Don’t put off responding to the request hoping itwill ‘go away’ – it won’t.Don’t worry about having been asked for astatement – discuss your statement with your linemanager.Release of Patient RecordsOriginals of records must not be released without the agreement of the Director or Caldicott Guardian.In most circumstances, copies must be taken and the Trust must retain the originals. Occasionally theCoroner/Police will request the originals and in these circumstances they can be provided, but a copyset should still be retained by the services. Where a legal representative is requesting original or copymedical records, Data protection department should be informed.Support to StaffIt is recognized that being involved in a serious incident and its subsequent investigation or inquestcan be stressful and difficult for staff. The member of staff should contact their ServiceManager/Patient Safety Lead to agree what support the Trust can provide. This may involve furtherinvolvement of the Trust’s solicitors, including advice prior to the court hearing, arranging for staff to bebriefed on the process; and/or having legal representation available; and/or having legalrepresentation available; and/or having access to the Staff Counsellor within the Occupational HealthDepartment. As a minimum, the member of staff should be accompanied to court either by acolleague, or their line manager49

Forensic Readiness guidanceAppendix XIntroductionThis guidance relates to securing and protecting evidence relating to incidents where illegal orfraudulent misuse of information systems is suspected.Serious incidents of this nature should be investigated using the processes described in Section B ofthe Incident Management Policy. This inquiry may be conducted alongside a disciplinary investigationor a counter-fraud investigation, depending on the circumstances. These processes are outlined inthe Disciplinary Policy, Procedure and Rules and the Fraud Policy and Response Plan.Initial actions following discovery of an incidentAs soon as the Trust becomes aware of an incident, all parties that are required to take action shouldbe involved as early as possible. Only those essential to the investigation of the incident should beinvolved, eg ICT dept, HR dept, legal representatives, Local Counter Fraud Specialist (internal audit).If media interest is anticipated, the Communications Department should be informed.Details of the incident should be kept confidential and involve only those that have a clear need toknow as the more people who are aware of the incident, the more opportunity there is for people tointerfere, hamper or compromise the investigation. This helps to ensure the suspect (if there is one)does not become aware of the investigation and does not get any access through which they might beable to delete evidence or cover tracks.Investigators should be aware of collusion as there might be more than one offender working alone.Gathering and securing evidenceComputer systems should be checked only by trained security personnel to ensure that data essentialto the investigation is not destroyed or contaminated., whether they are authorised to do so not,because even turning a machine on or off could destroy or contaminate data, which may be essentialto the outcome of the incident.It is important to ensure that people with the right expertise are used who have the ability to accessand recover potential evidence correctly. Data collection for Computer Forensics can be performed intwo ways:• Overtly : openly acquiring the equipment to be used in an investigation• Covertly:allowing the activity to continue whilst gathering evidence and identifying theconspirators.Wherever possible, covert monitoring should always be considered in cases of employee misuse inorder to ease their return to work if the allegations are unfounded.Secure access to systems and evidenceWhere the alleged perpetrator is still in on site, it is important to ensure that evidence cannot bedestroyed before any interviews as part of the disciplinary process. During this process, the ICTdepartment may be requested to secure all system access such as:• Network access• E-mail• Privileged access• Remote access• Physical access.50

System owners may also be requested to secure access to systems managed outside of IT such as:• Finance systems• Clinical systems• Local Manual and IT systemsA list of IT Systems and their owners is held as an appendix to the ICT Security Policy on the intranet.It is important to ascertain whether the employee has access to a laptop, PDA device, USB (memorystick), CDs, DAT tapes or any other media and organise their retrieval.Re-instating user access/equipment on completion of the investigationWhere the incident has proven the subject to be innocent or where no further action is to be taken, thesubject’s access to systems and services should be resumed. However, a review of access rights maybe necessary if they contributed to the incident.Where action has been taken against the subject the equipment may need to be retained as evidencepending a court case or possible appeal. For fraud cases, it is recommended that the counter-fraudservices take responsibility for secure storage. For other types of incidents (eg misuse of Trust ITequipment for accessing and storing information from the internet) the investigating department willneed to ensure that arrangements are made for secure storage of equipment, either or site, or externalto the Trust. If the police or Crown Prosecution Service (CPS) are involved, then it is likely that theywill take responsibility for secure storage of equipment51

Appendix 11OXLEAS NHS FOUNDATION TRUSTPROCESS FOR CRITICAL INCIDENT/SUI NOTIFICATIONAll directorates will use the appropriate borough template (the 3 templates are includedbelow).For level 4 SUIs that result in a fatality and all level 5 SUIs, notification is sent by thedirectorate in which the SUI occurred to:For BexleyresidentsPCTMartin.murphy@bexley.nhs.ukLAKelley.geddes@bexley.gov.ukForBromleyresidentsNicola.wilson@bromleypct.nhs.ukPaula.morrison@bromleypct.nhs.ukDavid.roberts@bromley.gov.ukSuzanna.simpson@bromley.gov.ukGreenwich:notificationfor level 5SUIs onlyLangley.gifford@greenwichpct.nhs.uk Jay.stickland@greenwich.gov.ukDirectorates will send a copy of the notification to the relevant Oxleas borough lead directorfor information; that is:• Bexley incidents – notification to Estelle Frost• Bromley incidents – notification to Iain Dimond• Greenwich incidents – notification to Trevor EldridgeHelen SmithDeputy CEOOxleas NHS Foundation TrustMay 201152

Strictly ConfidentialGreenwich Critical Incident Notification FormThe information provided within this form must not be shared with external parties withoutwritten agreement from Trevor Eldridge, Oxleas service director 1 or commissioners at theGreenwich Business Support Unit (BSU).RiO Number ……………………NHS Number ………………………..Level of Incident: [Oxleas Classification]Name …………………………..Date of incident being reported …………….TitleSexDate of BirthPlace of incidentPermanent addressTelephone numberMarital statusNext of KinName:Relationship:Address:Telephone number:Is the client currently in receipt of a service from Oxleas?Team/ward providing the service:□ Yes □ NoConsultant psychiatrist:1 Trevor Eldridge can be contacted on 020 8836 8543.53

Strictly ConfidentialIf an employee of Oxleas NHS Foundation Trust or London Borough ofGreenwich, what is their place of work?Registered GP Name:Address:Care co-ordinatorTelephone:Duration of contact with the service[e.g. 01.05.2008 – 25.03.2009]Brief description of the nature of the incident being reported:[Please use a continuation page, if necessary]Is there involvement from the Coroner’s Office?Is there Police involvement?Form completed by:□ Yes□ Yes□ No□ NoName………………………………Designation ………………………...What is the process for following this incident up [next steps]?NB: any agency that receives a press enquiry about this incident will immediatelynotify the press offices of Oxleas NHS Foundation Trust, Greenwich BSU orGreenwich Council.54

Strictly ConfidentialBexley Critical Incident Notification FormThe information provided within this form must not be shared with external parties withoutwritten agreement from Estelle Frost 1 , Oxleas service director or commissioners at the BexleyBusiness Support Unit (BSU).RiO Number ……………………NHS Number ………………………..Level of Incident:[Oxleas Classification]Name …………………………..Date of incident being reported …………….TitleSexDate of BirthPlace of incidentPermanent addressTelephone numberMarital statusNext of KinName:Relationship:Address:Telephone number:Is the client currently in receipt of a service from Oxleas?Team/ward providing the service:□ Yes □ NoConsultant psychiatrist:1 Estelle Frost can be contacted on 020 8301 943055

Strictly ConfidentialIf an employee of Oxleas NHS Foundation Trust or London Borough of Bexley,what is their place of work?Registered GP Name:Address:Care co-ordinatorTelephone:Duration of contact with the service[e.g. 01.05.2008 – 25.03.2009]Brief description of the nature of the incident being reported:[Please use a continuation page, if necessary]Is there involvement from the Coroner’s Office?Is there Police involvement?Form completed by:□ Yes□ Yes□ No□ NoName………………………………Designation ………………………...What is the process for following this incident up [next steps]?NB: any agency that receives a press enquiry about this incident will immediatelynotify the press offices of Oxleas NHS Foundation Trust, Bexley BSU or BexleyCouncil.56

Strictly ConfidentialBromley Critical Incident Notification FormThe information provided within this form must not be shared with external parties withoutwritten agreement from Iain Dimond 1 , Oxleas service director or commissioners at theBromley Business Support Unit (BSU).RiO Number ……………………NHS Number ………………………..Level of Incident:[Oxleas Classification]Name …………………………..Date of incident being reported …………….TitleSexDate of BirthPlace of incidentPermanent addressTelephone numberMarital statusNext of KinName:Relationship:Address:Telephone number:Is the client currently in receipt of a service from Oxleas?Team/ward providing the service:□ Yes □ NoConsultant psychiatrist:1 Iain Dimond can be contacted on 0208 295 8067.57

Strictly ConfidentialIf an employee of Oxleas NHS Foundation Trust or London Borough ofBromley, what is their place of work?Registered GP Name:Address:Care co-ordinatorTelephone:Duration of contact with the service[e.g. 01.05.2008 – 25.03.2009]Brief description of the nature of the incident being reported:[Please use a continuation page, if necessary]Is there involvement from the Coroner’s Office?Is there Police involvement?Form completed by:□ Yes□ Yes□ No□ NoName………………………………Designation ………………………...What is the process for following this incident up [next steps]?NB: any agency that receives a press enquiry about this incident will immediatelynotify the press offices of Oxleas NHS Foundation Trust, Bromley BSU or BromleyCouncil.58