Incident reporting policy - Homerton University Hospital

13.0 Reporting to external agenciesSenior Managers and Assistant General Managers for Quality and Risk will be responsible for ensuringescalation of incidents to the Clinical and Non-Clinical Risk Managers where they are graded as major /catastrophic (Red – Refer to Trust Matrix at Appendix 1) that may require notification to the NationalPatient Safety Agency (NPSA). These incidents will however, be normally reviewed through the IncidentReview Group (See Appendix 3)The Clinical and Non-Clinical Risk Manager(s) will then escalate this requirement to the Head ofGovernance and/or Chief Nurse who will then make the final decision as to the level of investigationrequired and whether the incident requires a Serious Incident Investigation or should be onward reportedas a Serious Untoward Incident.Local Supervising Authority Midwifery Officer should be informed of all incidents graded as major /catastrophic (Red) midwifery incidents and / or maternal deaths.In addition, there will be a requirement to report incidents to other external bodies within prescribedtimescales as outlined in Appendix 4.13.1 Other External Agencies13.1.1 National Patient Safety Agency (NPSA)The NPSA is a special Health Authority established to ensure that the National Health Service learns fromAdverse Patient Incidents involving patients so that improvements to the delivery of healthcare and thesystems supporting care can be made for the benefit of patients in the future.To support this the NPSA has established the National Reporting and Learning Service (NRLS).Thefunction of the NRLS is to collect and analyse patient safety incidents, including prevented patient safetyincidents (near misses) and provide feedback to healthcare organisations in a way that promotes learningand risk reduction through environmental and / or system changes in organisational, management orclinical practice.Reporting to the NPSA / NRLS is conducted by the Risk Management team.The Trust, through the Risk Management Dept, will upload all clinical patient safety incidents to the NPSAon a bi-weekly / monthly basis.Any incident that involves the unexpected death of a patient must be reported to the NPSA13.1.2 Strategic Health Authority (SHA)In line with the NHS London Serious Untoward Incident Reporting Policy including the procedure to befollowed for Safeguarding Children (2009) and the Contract for NHS Services with the commissioningPCT, the Trust will report all SUI‟s to City & Hackney Teaching PCT. The trust will ensure that the PCT isinformed via upload of all SUI incidents to the STEISS database managed by NHS London.Though it is not compulsory for Foundation Trusts to report SUIs to NHS London as there is no direct lineof accountability, the trust will aim to participate in the established reporting system in order to contribute tothe learning from the wider reporting of SUIs. Where there is a concern that other organisations could beat risk of a similar incident occurring (such as an equipment malfunction) the trust will inform NHS Londonat the earliest opportunity as well as other appropriate bodies (e.g. the MHRA).14.0 Escalation of Reported Incidents14.1 All reported incidents are systematically analysed to identify trends and produce information formanagement review and action. Details of reported accidents are provided to the following groups:14.2 Patient Safety CommitteeMeest on a monthly basis and receives an update of all current serious incidents. The committee receivescompleted serious incident investigation reports, ratifies, or otherwise, the report recommendations andensures that appropriate action plans are put in place.Page 11 of 47