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

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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
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 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: Appendix VIIIOXLEAS NHS FOUNDATION
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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