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

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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
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 18 and 19: 3 INITIAL SERVICE MANAGEMENT REVIEW
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: Date of discharge from most recent
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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