Incident Management Policy Including Serious Incidents Requiring ...

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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
Executive SummaryComplete this summary AFTER the main report has been written. This forms an important précis of the report.Brief incident description:Incident date:Incident type:Healthcare Specialty:Actual effect on patient and/or service:Actual severity of incident:Level of investigation conductedInvolvement and support of the patient and/or relativesDetection of the incidentCare and service delivery problemsContributory factorsRoot causesLessons learnedRecommendationsArrangements for sharing learningincident management policy 2011 with SUI v3 FINAL 33/51
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 18 and 19: impending court hearing or out of c
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 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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