Incident Management Policy Including Serious Incidents Requiring ...

ContentsExecutive Summary 33MAIN REPORT: 34Incident description and consequences 34Pre‐investigation risk assessment 34Background and context 34Terms of reference 34Level of investigation 35Involvement and support of patient and relatives 35Involvement and support provided for staff involved 35Information and evidence gathered 35FINDINGS: 36Chronology of events 36Detection of incident 36Notable practice 36Care and service delivery problems 36Contributory factors 36Root causes 36Lessons learned 36Post‐investigation risk assessment 36CONCLUSIONS: 36Recommendations 37Arrangements for Shared Learning 37Distribution List 37Appendices 37Action Plan 37incident management policy 2011 with SUI v3 FINAL 32/51