Incident reporting policy - Homerton University Hospital

the Clinical Risk Manager to the relevant senior management team for the appropriateDivisions/Directorates for formal agreement with the recommendations. As a minimum the report shouldbe circulated to the relevant Clinical Director, General Manager and Head of Nursing.Following review by the Division/Directorate the Executive Director must:• Confirm the report is ready to go to the Patient Safety Committee• Confirm how feedback will be given to staff/patients/relative involved• Lead on any urgent actions if not already actioned.Reports from level 3 investigations must be reviewed by the Chief Executive and the Executive Directorprior to Division/Directorate review and presentation to the PSC in case additional action is required22.16 SUI Report and recommendation ratification and follow-up action2.16.1 Patient Safety CommitteeThe findings of the report, including recommendations and a proposed action plan will be presented to thePatient Safety Committee for ratification by the Lead Investigator or, where appropriate, by the ExecutiveDirector.The ratified report and the action plan must be stored on the Datix database as a document relating to theoriginal incident report form.22.16.2 Follow up actionThe ratified report and action plan will be sent to the relevant Directorates Clinical Director, Head of Nursing,General Manager and Governance Lead by the Clinical Risk Manager.The Divisional Clinical Director, General Manager and Head of Nursing must identify a lead person and a timescale for completion for each recommendation in the action plan, then return the populated action plan to theClinical Risk Manager.The Clinical Risk Manager will maintain a spread sheet of all open recommendations.The Patient Safety Committee will follow up all outstanding actions from all open SUI‟s at each meeting.SUI‟s should not be closed on Datix until all actions have been completed.The final report, including all appendices and related documentation (e.g. statements collected) must beforwarded to the Risk Management Department for central filling.22.16.3 Clinical Governance CommitteeA summary of all SUIs and progress against action plans must go to each meeting of the Clinical GovernanceCommittee.22.16.4 Clinical and Trust BoardThe Clinical Board and the Board of Directors will receive formal updates every 6 months on progress of all“open” recommendations.22.16.5 Patient/RelativesOnce the report has been ratified by the Patient Safety Committee either; a meeting must be arranged by theExecutive Director must determine and record how the report and outcome of the investigation should with thepatient/relatives. If the patient/relative do not wish to meet with Trust staff a letter summarising the outcome ofthe investigation must be sent to them (unless they have previously refused this).22.15.7 Staff involved/affected by the incidentOnce the report has been ratified by the Patient Safety Committee the Executive Director must arrange for thestaff involved/affected to receive feedback about the investigation and the root cause analysis.Page 25 of 47