Incident Management Policy Including Serious Incidents Requiring ...

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Action requiredMonitoring requiredExamples of casesGrade 2Case will be monitored by theSHA/PCT/LA in conjunctionwith the provider organisation.The SHA will review findings,recommendations andassociated action plans.For Never Events, thecommissioning PCT will beobliged to monitor overallnumbers and actions andreport these in its annualreporting arrangementsComprehensiveInvestigation (RCA level 2investigation)(as above) or IndependentInvestigation (RCA level 3Investigation)*SHA/PCT monitoring Incidents leading to anindependent investigation orinquiry or those considered highrisk will continue to bemonitored by the SHA/PCT orLocal Authority until evidence isprovided that each action pointhas been implemented.Incidents involving adult or childabuse are referred to localsafeguarding arrangements Publish quarterly reportsTimescales: For IndependentInvestigations allow up to 26weeks/6 months for completion ofinvestigation. Extensions can begranted on an individual case-bycasebasis by the SHA/PCT.Maternal deathsInpatient suicides (includingfollowing absconsion)*Child protectionData loss and informationsecurity (DH Criteria level3-5)Never EventsAccusation of physicalmisconduct or harm ismadeHomicides following recentcontact with mental healthservices** Mental Health incidentsshould refer to DH guidance:Independent investigation ofadverse events in mental healthservices24 of 28
14.2 The investigation and final reportThe investigation and final report with recommendations for a serious incidentrequiring investigation should be completed as soon as possible and there is anexpectation that completion will be within 60 days of the incident. All final reportsfrom SUI’s are to be sent to the Head of Governance and there is a requirement toprovide an update every fourteen days until the completion of the investigation. TheHead of Governance will provide support and guidance in regard to the investigationprocess if requiredSerious incidents should only be closed on STEIS following the receipt of a robustinvestigation report that has been generated following a full root cause analysis. Asa minimum, reports should include:root cause(s);lessons learned;have a time-bound action plan.15 Never eventsThe National Patient Safety Agency define Never events as:"Never events" are very serious, largely preventable patient safety incidents thatshould not occur if the relevant preventative measures have been put in place. To bea “never event”, an incident must fulfil the following criteria;The incident has clear potential for or has caused severe harm/death.There is evidence of occurrence in the past (i.e. it is a known source of risk).There is existing national guidance and/or national safety recommendationson how the event can be prevented and support for implementation.The event is largely preventable if the guidance is implemented.Occurrence can be easily defined, identified and continually measured.”The 2011 list of events considered Never Events is shown at Appendix D. All reportableNever Events are Serious Incidents Requiring Investigation and should one occur, the SUIprocedure outlined in the flowchart above must be followed.16 Management of Serial IncidentsA serial incident is one where multiple enquiries by patients/public/media are anticipated forexample where a member of staff has been found to be carrying an infectious disease whichcould have impacted many patients. Guidance on managing such incidents can be found inthe Major Incident Policy.25 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
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Page 20 and 21: Category 0 1 2 3 4 5Impact No signi
Page 22 and 23: Peninsula Community HealthSERIOUS I
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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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