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

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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
Page 2 and 3: VERSION CONTROLDocument LocationOxl
Page 4 and 5: PART AINTRODUCTION1.1 Oxleas NHS Fo
Page 6 and 7: to the Senior Officer within HR who
Page 8 and 9: Head of Safeguarding Children and L
Page 10 and 11: 2 REPORTING AND IMMEDIATE ACTION2.1
Page 12 and 13: Immediate Within 24 Hours Within 3
Page 14 and 15: HOMICIDEHomicideNHSLondongrade 2Imm
Page 16 and 17: 2.3 Reporting to external agenciesC
Page 20 and 21: - individual factors;- task factors
Page 22 and 23: 4.1 InformationVictims, families an
Page 24 and 25: Directorate investigations reports
Page 26 and 27: Type of incident Level 1NegligibleA
Page 28 and 29: Type of incident Level 1NegligibleL
Page 31 and 32: Appendix IIIIncident report form to
Page 33 and 34: Guidance notes for completing adver
Page 35 and 36: SERIOUS INCIDENTAppendix VPRIVATE A
Page 37 and 38: Date of discharge from most recent
Page 39 and 40: • Ensure that TOR’s and timesca
Page 41 and 42: Where the LSCB TOR includes service
Page 43 and 44: Appendix VIIIOXLEAS NHS FOUNDATION
Page 45 and 46: 5. CONTENT OF THE INVESTIGATION5.1
Page 47 and 48: Guidelines on writing witness state
Page 49 and 50: The following ‘‘do’s’’ an
Page 51 and 52: System owners may also be requested
Page 53 and 54: Strictly ConfidentialGreenwich Crit
Page 55 and 56: Strictly ConfidentialBexley Critica
Page 57 and 58: Strictly ConfidentialBromley Critic

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