Incident Management Policy Including Serious Incidents Requiring ...

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Grade 2 (requiring independent investigation such as Homicide Investigations) –Internal investigation should be completed within 60 working days from the date ofthe incident. Where an independent investigation is commissioned this should becompleted within 26 weeks from the date of commissioning.6. Serious 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.7. Serious incidents can be closed by the Commissioning PCT or the SHA before thecompletion of an action plan if assurance is received of ongoing monitoring ofimplementation. The exception to this is grade 2 incidents where an independentinvestigation has taken place. In these cases, the Commissioning PCT and the SHAwill continue to monitor the action plan and only close the incident once assurancehas been received that all action points have been completed.8. Providers are requested to update the PCT by the 10 th of each month on theprogress of the investigation of each SIRI.Process for the management of grade 2 serious incidentsGrade 2 incidents are defined as:a never event as defined by the National Patient Safety Never Event Framework2010 (Page 37 National Framework) a homicide or any incident falling into the definitions as defined by HRG 96 (27)that require or may require an independent investigation (see section 3 of thissection for further guidance);an inpatient suicide (including following absconsion);adult safeguarding incident;maternal death;child safeguarding incident data loss and information security (Department of Health criteria level 3-5);grade 4 pressure ulcer;accusation of physical misconduct or harm is made;significant media interest;serious failure of screening services where there is a mis-diagnosis or clinicalincident e.g. perforation.incident management policy 2011 with SUI v3 FINAL 42/51
The incident should be reported by the provider organisation to STEIS within twoworking days of the organisation becoming aware of the incident.Where possible the incident will be reviewed by the NHS CIOS the next working day.The provider organisation should complete a 72 hour management report fordistribution to the SHA and Commissioning PCT. Such a report should include thefollowing:- date and location of incident and STEIS identification number;- initials, gender and date of birth of client;- incident type; e.g. Never Event;- brief details leading up to the incident to include care and treatment;- immediate actions taken;- chronology of contacts.The internal investigation should be completed within 60 working days following thereporting of the incident. The completed investigation report will be shared with theCommissioning PCT who will forward the report to the SHA. The SHA andCommissioning PCT will provide feedback and report back to the reportingorganisation within 20 working days.Process for the monitoring of grade 2 incidents such as homicidesThe incident should be reported by the provider organisation to the Commissioning PCT andthe SHA as soon as notification is received, such notification may in the first instance bemade by telephone.The incident should be formally reported to STEIS within two working days of theorganisation becoming aware of the incident.All organisations should ensure that the appropriate communication leads have been notifiedand that media handling processes are in place.The provider organisation should complete a 72 hour report for distribution to the SHA andCommissioning PCT. The report should include:- date and location of Incident and STEIS identification number;- initials, gender and date of birth of client;- incident type; e.g. homicide;- date of first referral and last contact with Mental Health Services;- details of treatment type; e.g. CPA or inpatient treatment status;- brief details leading up to the incident to include care and treatment;incident management policy 2011 with SUI v3 FINAL 43/51
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 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 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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