Incident Management Policy Including Serious Incidents Requiring ...

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impending court hearing or out of court settlement in cases of large scale litigation,including negligence claims (as defined by the NHS Litigation Authority (NHSLA)large scale claims are considered to be those over £250,000);Mortality/Morbidity/Care <strong>Incident</strong>sunexpected or unexplained death while in NHS care (including community nursingand health visiting);suspicion of a serious error or errors by a member of staff, primary care contractor orother healthcare contractor;a serious drug error, such as mal-administered spinal injections;the suicide of any person currently in receipt of NHS Mental Health services on or offNHS premises, or who has been discharged from NHS Mental Health Services withinthe last twelve months. Suicide is defined as death:ooowhere there is obvious evidence or strong suspicion of self harm;where the above does not apply initially but emerges later from a clinicalreview of the case, or discussion at the incident monitoring group;where the Coroner’s verdict is suicide (or open verdict);death or injury where foul play is suspected, including abuse or neglect;situations when a patient requires additional intervention(s) as a result of failures inthe diagnosis process;the accidental death of, or serious injury to, a patient, a member of staff, or visitor toNHS or primary care premises, or involving NHS or primary care staff or equipment;significant harm to a vulnerable adult where reported under the Protection ofVulnerable Adults procedures. This could be defined as:oooothe death of a vulnerable adult where abuse or neglect is suspected to be afactor in the death;when a vulnerable adult has suffered significant injuries suspected to be as aresult of abusewhere a vulnerable adult has suffered further harm as a result of a healthcare worker failing to follow procedureswhen a serious case review is to be undertakensignificant harm to a child where reported under the local child protectionprocedures. This could be defined as:ooooa child death where abuse or neglect is suspected to be a factor in the deathwhen a child has suffered significant injuries suspected to be as a result ofchild abusewhere a child has suffered further harm as a result of a health care workerfailing to follow procedureswhen a serious case review is to be undertakenchildren and adults with complex health needs failing to obtain their assessed andagreed packages of health care, thus putting their health at serious riskout of county critical care transfers or any other transfer that could have resulted in aserious incident requiring investigationabuse which has been perpetrated within the remit of the organisation; this may beabuse by a member of staff, visitor or member of the public18 of 28
Safety and Governance <strong>Incident</strong>sserious complaints about a member of staff or primary care contractor or any incidentrelating to a staff member where adverse media interest could occurthe exclusion of employed doctors or dentists under the disciplinary procedures thatrefer to ‘High Professional Standards in the Modern NHS: a framework for the initialhandling of concerns about doctors and dentists in the NHS’ (HSC 2003/12)significant disciplinary matters of other staffserious verbal and/or physical aggression, whether involving staff or patients,including that based on ethnicity, gender, sexuality, age, disability or other equalityand diversity issuea serious breach of confidentiality, whether affecting staff or patients; particularlyincidents where personal medical information or data that could lead to identity fraudor have other significant impact on individuals has been lost or has got into the publicdomainserious damage which occurs on the premises of Peninsula Community Health orany incident which results in serious injury to any individual or serious disruption toservices (such as evacuation of patients due to fire)failure of equipment so serious as to endanger life, whether or not injury resultssuspicion of malicious activity, such as tampering with equipmentcircumstances that lead to the provider no longer being able to provide an element ofservice and not reportable through SITREP (such as closure of caseloads to newreferrals)abuse which has been perpetrated within the remit of the organisation; this may beabuse by a member of staff, visitor or member of the publicinformation governance incidents such as the loss or inappropriate release ofsensitive/personal/confidential information which fall into category 3, 4 or 5 below:19 of 28
Page 1 and 2: Peninsula Community HealthIncident
Page 3 and 4: 17 Performance Management and Data
Page 5 and 6: the case of those in receipt of men
Page 8 and 9: Director of Finance will Retain ove
Page 10 and 11: No harm/minimal harmAny immediate a
Page 12 and 13: 7 External Stakeholder Notification
Page 14 and 15: 8.3 NHS Litigation AuthorityThe Nat
Page 16 and 17: If a staff member is contacted by t
Page 20 and 21: Category 0 1 2 3 4 5Impact No signi
Page 22 and 23: Peninsula Community HealthSERIOUS I
Page 24 and 25: Action requiredMonitoring requiredE
Page 26 and 27: 17 Performance Management and Data
Page 28 and 29: 23 Referenceso Data Protection Act
Page 30 and 31: ContentsExecutive Summary 33MAIN RE
Page 32 and 33: MAIN REPORT:Incident description an
Page 34 and 35: FINDINGS:Chronology of eventsChrono
Page 36 and 37: Appendix B - Organisational Risk Ma
Page 38 and 39: Consequence score (severity levels)
Page 40 and 41: Grade 2 (requiring independent inve
Page 42 and 43: - immediate actions taken;- details
Page 44 and 45: will continue to monitor the action
Page 46 and 47: Where an incident meets the require
Page 48 and 49: Wrong routeadministration ofchemoth
Page 50 and 51: Initial Equality and Human Rights I
Page 52 and 53: 3. How does it impact on people’s

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