Incident Management Policy Including Serious Incidents Requiring ...

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