INCIDENT REPORTING POLICY JUNE 2019 Reporting Policy... · INCIDENT REPORTING POLICY_RM03_JUNE 2019 ii Contents Page POLICY SUMMARY FOR STAFF 1 Introduction 1 2 Aims and objectives

INCIDENT REPORTING POLICY JUNE 2019

This policy supersedes all previous policies for Incident Reporting.

INCIDENT REPORTING POLICY_RM03_JUNE 2019 i

Policy title Incident Reporting Policy

Policy reference

RM03

Policy category Risk Management

Relevant to All Trust staff

Date published July 2019

Implementation date

July 2019

Date last reviewed

May 2019

Next review date

July 2021

Policy lead Margaret O’Driscoll, Risk and Patient Safety Manager

Contact details Email: [email protected] Telephone: 020 3317 6564

Accountable director

Linda McQuaid, Interim Director of Nursing

Approved by (Group):

Quality Committee

Approved by (Committee):

Quality Committee 17 November 2015

Document history

Date Version Summary of amendments

Jan 06 1 New Policy

Jun 08 2 Review

Aug 11 3 Review

Oct 15 4 Strengthening the guidance on use of Datix (online)

Apr 16 4.1 Updated to reflect transfer of responsibilities for patient safety to NHS Improvement (NHS/PSA/RE/2016/003)

Jun19 5

Introduced minimum standards for incident management Refreshed guidance for Handlers and Specialist Leads Refreshed guidance on use of DatixWeb

Membership of the policy development/ review team

Margaret O’Driscoll, Risk and Patient Safety Manager Samantha Barclay, Risk and Patient Safety Manager Kevin Cann, Risk and Patient Safety Manager Karen Reynolds, Head of Governance and Quality Assurance Emma Francis, Complaints and Incidents Manager

Consultation Linda McQuaid, Interim Director of Nursing David Curren, Deputy Director of Nursing

Heads of Nursing

David Hodgkinson, Health & Safety Manager

Lucy Reeves, Chief Pharmacist

Svetlana Jankovic, Medicines Safety Officer

Lynn Taylor, LSMS

John Griffin, Head of Emergency Planning Response & Resilience

Gerard Kursten, Interim IG Manager

Associate Divisional Directors

Clinical Divisional Directors

DO NOT AMEND THIS DOCUMENT

Further copies of this document can be found on the Foundation Trust intranet.

INCIDENT REPORTING POLICY_RM03_JUNE 2019 ii

Contents Page

POLICY SUMMARY FOR STAFF

1 Introduction 1

2 Aims and objectives 2

3 Scope of the policy 2

4 Definitions 3

PART I - RESPONSIBILTIES FOR ALL STAFF

5 Procedure for reporting when an incident occurs 6

6 Hazards 6

7 Anxieties about reporting 7

8 Being open and Duty of Candor 8

9 Information Governance 8

PART II – ADDITIONAL RESPONSIBILITIES FOR MANAGERS, HANDLERS AND SPECIALIST LEADS

10 Maintaining safety 9

11 Reporting and follow up of incidents 9

12 Service Managers 10

13 Governance & Quality Assurance Department 11

14 Additional follow up of incidents 11

15 Timescales for incident management 12

16 Support for staff 12

17 A learning culture 13

18 Responsibilities of specialist staff 15

19 Reporting and other requirements for incidents of specific types 16

20 Dissemination and implementation arrangements 21

21 Training requirements 21

22 Monitoring and audit arrangements 21

23 Review of the policy 21

24 References 22

25 Associated documents 22

INCIDENT REPORTING POLICY_RM03_JUNE 2019 iii

Appendix 1: Trigger List Summary 23

Appendix 2: Degree of harm 24

Appendix 3: Guidance for rating risk 25

Appendix 4: Incident Reporting Guide (Leaflet) 28

Appendix 5: DatixWeb Incident Form (DIF1) User Guide 30

Appendix 6: Datix Investigation Guide For Handlers and Specialist

Leads (On-line User Guide)

33

INCIDENT REPORTING POLICY_RM03_JUNE 2019 1

POLICY SUMMARY FOR STAFF

Minimum Standards for Incident Management

Incident Reporting

All Incidents will be reported online via DatixWeb and will adhere to the following

minimum standards:

Timely: All incidents will be reported as soon as is practicable, and certainly within the same shift or span of duty.

Accurate: Reporters will clearly state the facts of the incident as known at the time of reporting e.g. what, when, where, who was involved

Relevant: All incident reports will only contain information that is relevant to the incident

Objective: Reporters will only use neutral and professional language to describe the incident.

Incident Handling

All Incidents will be reviewed by the Handler who will adhere to the following minimum

standards:

Timely: Handlers will review and sign off incidents within 5 days of the incident being reported.

Investigate: Handlers will ensure all incidents are investigated to confirm what happened and why.

Accurate: Following the investigation Handlers will ensure the outcome of all incidents, including the actual level of harm is accurately recorded in the incident report.

Feedback: Handlers will record follow-up actions, lessons learned and will feedback to those involved in the incident.

1. Introduction

1.1 Adverse incidents occur in every organisation. In most cases, even where human error is involved, careful consideration reveals related organisational failings, which need to be addressed.

1.2 The Trust requires all staff to report any incident or near miss that they witness or are

involved in whilst at work, however trivial it may appear. Information from incident reports is used:

to allow learning to take place; to allow necessary actions to be taken to reduce future risks; to enable trends to be analysed, with a view to appropriate targeting of resources; to identify training needs; to inform Clinical Risk Assessment, Care Planning, Behavioural Support Plans, for

individual service users; to measure performance; to meet legal requirements; to ensure that the Trust meets certain external reporting requirements;


1.3 All members of staff have an important role to play in identifying, assessing and managing risk. The Trust needs all staff to feel confident in reporting incidents, knowing that reporting will not result in disciplinary procedures or blame. The Trust operates a ‘fair and open culture’ in relation to risk management. All staff are encouraged to report any situation where things have, or could have gone wrong.

1.4 Providing the full facts are disclosed, no disciplinary action will be taken as a result of

an investigation process. However, appropriate action in accordance with Trust policies will be taken when an employee has acted:

Illegally - against the law (e.g. assaulting a colleague).

Maliciously - intending to cause harm, which s/he knew was likely to result (e.g. deliberately releasing confidential information).

Recklessly - deliberately taking an unjustifiable risk where s/he either knew of the risk or s/he deliberately closed his/her mind to its existence (e.g. working while under the influence of alcohol or repeatedly making the same careless mistake).

Concerns regarding unsafe practice may be reported by staff through a confidential route outlined in the Raising Concerns at Work Policy.

2. Aims and objectives

This policy aims to ensure:

That staff are aware of the procedures to follow when an incident has occurred.

That the reporting arrangements and the actions that will be taken in terms of communication and follow up when an incident occurs are understood by all staff.

That the organisation learns from incidents and promotes improvements in

practice.

3. Scope of the policy

3.1 This policy is relevant to all Trust staff.

3.1 All staff, including agency and temporary staff, are required to be aware of the

information included in Part I of this policy. All staff with managerial responsibility, and any staff member who may at any time be delegated to take such responsibility in the absence of a manager, are additionally required to be aware of the procedures in Part II of this policy.

3.2 This policy should be read in conjunction with the Management of Serious Incidents

Policy, which serves to outline the processes and procedures for the reporting and investigation of incidents that meet criteria for a Serious Incident.


4. Definitions

4.1 Incident. The term ‘Incident’ is used in this policy to refer to any occurrence, which gives rise to (or, in the case of a near miss narrowly avoids giving rise to) unexpected or unwanted effects involving the safety or well-being of any person on Trust premises, employed by the Trust or in receipt of Trust services. It also refers to the loss of or damage to property, records or equipment that are on the Trust premises or belong to the Trust. The term therefore includes accidents, clinical incidents, security and confidentiality breaches, violence, and any other category of event, which does or could result in harm. It also includes failures of medical or other equipment.

4.2 Near Miss. A near miss is any occurrence which has the potential to cause harm, but

harm is prevented because intervention or evasive action is taken. For the purposes of this document, the term ‘Incident’ includes near misses.

4.3 Trigger List: The Trust has an agreed ‘Trigger List’ which may be found in Appendix 1.

The trigger list details the kinds of incident that could occur in the Trust. The list serves to assist staff in understanding what kinds of events should be reported. This list is not exhaustive however, so any other occurrence that causes concern should also be reported.

4.4 Hazard. A ‘Hazard’ is a situation or state of affairs which may or may not give rise to

harm, loss or damage as described under title Incident above. 4.5 Major Incident. The NHS defines a ‘Major Incident’ as “Any occurrence that presents

serious threat to the health of the community, disruption to the service or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by hospitals, ambulance trusts or primary care organisations.”

For NHS organisations, major incidents are defined in terms of levels. These are:

Level 0 – Green An incident requiring health support that can be responded to and managed by local health organisations within their respective business as usual capabilities.

Level 1-Yellow -. An incident affecting a number of health organisations and/or a number of health organisations requiring support.

Level 2 - Amber Large scale events affecting potentially hundreds rather than tens of people, possibly also involving the closure or evacuation of a major facility (e.g. because of fire or contamination) or persistent disruption over many days; these will require a collective response by several or many neighbouring trusts.

Level 3- Red - events of potentially catastrophic proportions that severely disrupt health and social care and other functions (power, water etc.) and that exceeds even collective capability within the NHS and may require national coordination.

In the case of an incident meeting these criteria, the Major Incident Policy and Business Continuity Plans should be followed in the first instance.

4.6 Serious Incident. The term covers incidents / near misses which generally meet the

criteria as ‘Severe’ or ‘Catastrophic’ under the standard risk rating scale agreed by the Trust (see Appendix 3) but other factors such as the potential for harm and the


potential for learning are also taken into consideration when deciding if an incident meets the threshold for investigation under the serious incident policy. In the case of an incident meeting the Serious Incident threshold, the Management of Serious Incidents Policy should be followed. An incident may be considered a Serious Incident in case of:

- an unexpected or avoidable death of a service user, visitor, member of the public

or member of staff; - permanent or significant harm to a service user, visitor, member of the public or

member of staff; - a ‘never event’. Please see the Management of Serious Incidents Policy for an

up-to-date list of ‘never events’ as defined by NHS England; - serious outbreak of infection; - serious data loss or breach of service users’/staff confidentiality; - significant failure in Safeguarding responsibilities; - serious damage to Trust property.

This list is not exhaustive. When in doubt about whether an incident is serious or not, staff should contact The Governance & Quality Assurance Department for advice. Cases of possible fraud involving Trust service users, staff or suspected criminal activity should be reported directly to the Trust’s Local Counter Fraud Specialist, who will report the matter as a Serious Incident if appropriate. Further guidance and contact details can be found on the Trust Intranet.

4.7 Staff. The term ‘Staff’ is used in this policy to refer to:

- individuals employed by the Camden and Islington NHS Foundation Trust (‘the Trust’), whether in a clinical or non-clinical role;

- individuals employed by other organisations, including partner NHS organisations, Local Authorities, contractors or temporary staffing agencies, volunteers whilst they are involved in the provision of care to service users under the management of a Trust clinical team, or undertaking other work on behalf of or under the aegis of the Trust.

All staff will follow the procedures outlined here. In the event of an incident involving staff not directly employed by the Trust, guidance will be given on these procedures from appropriate Trust managers.

4.8 Manager. Throughout this document, the term ‘Manager’ is used to refer to the person with first line management responsibility for a team or department at the time when an incident takes place, whether this person is the Head of Department, the Team Manager, or another person with delegated responsibility at the time of the incident.

4.9 Handler. The term ‘Handler’ is used in DatixWeb and refers to the manager of the

team or department at the time when an incident takes place. The ‘Handler’ must review the incident; ensure the incident is investigated; amend and update the incident if necessary to accurately reflect what happened; record the follow-up actions taken and any lessons learned; provide feedback to the person reporting the incident; and approve the incident once all the necessary steps have been taken to manage the incident correctly.

4.10 Specialist Lead. The term ‘Specialist Lead’ refers to a senior manager in the Trust who has the appropriate expertise to provide advice and recommendations in relation to actions following an incident. ’Specialist Leads’ are automatically informed of all


incidents appropriate to their area of expertise. A ‘Specialist Lead’ must review the incident and provide support to the ‘Handler’ to ensure the appropriate follow-up actions are taken to manage the incident correctly. The Specialist Lead must record their recommendations and comments on the incident form.

4.11 Service Manager. The term ‘Service Manager’ is used to denote the second in line

manager, i.e. the person who manages the Team Manager and includes Matrons/Lead Nurses or the Head of Department.

4.12 Service User. A recipient of clinical services provided by the Trust. 4.13 DatixWeb. The term ‘DatixWeb’ refers to the Trust electronic incident reporting

system. This can be accessed via the home page of the Trust Intranet in the ‘Quick Links’ section:


PART I - RESPONSIBILITIES FOR ALL STAFF

5. Procedure for Reporting when an Incident Occurs

5.1 When an incident occurs, staff present will take immediate steps to contain the incident and to minimise harm. The manager or the person in charge will be informed immediately.

5.2 A number of Trust policies give guidance on action that may need to be taken in the

case of particular types of incident (see section 19). 5.3 In the case of equipment failure, the defective equipment will be withdrawn from use

and retained securely for further examination. Any other evidence that may be pertinent to the investigation of the incident will likewise be retained.

5.4 As soon as is practicable, and certainly within the same shift or span of duty, an

incident report will be completed on DatixWeb by a member of staff that witnessed or was involved in the incident, or by another appropriate person. The manager (or person in charge, if the manager is not present) will in all cases be notified of the incident when it occurs.

5.5 The incident report will include full, clear details, and observations will consist of

known facts, not opinions. Completion of a report does not constitute an admission of liability of any kind on or by any person.

5.6 Where more than one person is affected by or involved in a single incident, details of

all persons, including any witnesses and the person reporting the incident will be detailed in the incident report on DatixWeb.

5.7 All incidents will be reported if they involve Trust staff carrying out their professional duty, regardless of the location of the incident. This includes for example, staff working in the community or staff that perform a liaison role to acute hospital environments or care homes.

5.8 All incidents must be reported online using a DatixWeb incident reporting form. This

form can be accessed via the Trust Intranet (see section 4.13). A confirmation email will be sent to the member of staff that reports the incident and to the Manager assigned as the Handler by the reporter. An email notification will also be sent to the relevant Specialist Lead, depending on the type of incident that has been reported. All Service Managers will be able to view incidents in Datix relating to the teams they manage. For details on reporting an incident using DatixWeb see the Trust’s Incident Reporting Guide (Appendix 4) and the DatixWeb Incident Form (DIF1) User Guide (Appendix 5).

6. Hazards

6.1 Any member of staff who becomes aware of a hazard that may not previously have been reported has a duty to report it using the DatixWeb incident reporting form.

6.2 Any hazard should be reported to the manager/deputy of the relevant team or

department, who will have a responsibility to take any action necessary to remove the hazard or otherwise to report it through appropriate channels.


7. Anxieties about Reporting

Very occasionally, circumstances may arise in which a member of staff is aware of an incident, near miss or hazard which should normally be reported under this procedure, but where, for specific reasons, the staff member feels unable to take this action.

Any staff member finding him/herself in this position should, if possible, seek guidance from a Trust Manager. If this is not acceptable or does not allow the situation to be resolved, the Raising Concerns at Work Policy, which provides information for anonymous reporting, should be followed.

8. Being Open and Duty of Candour

8.1 The Trust has a Being Open and Duty of Candour policy and follows the guidance

detailed in that policy when investigating incidents, complaints and claims. The Trust encourages open communication with teams, other healthcare organisations, staff, service users and carers when reporting, investigating and responding to incidents, complaints and claims.

8.2 Service users and/or their carers have a right to expect openness in their care.

When an incident has occurred or a complaint or claim is received, it is important that staff apologise as soon as possible and explain what has happened. Service users and/or their carers should be invited to take part in any investigation and seek to reassure them that any lessons learnt or recommendations made will aim to prevent reoccurrence. Staff need to ensure that service users and/or their carers who have been involved in an incident, complaint or claim are provided with support to cope with the physical and psychological consequences of what happened.

8.3 The Duty of Candour places a requirement on providers of health and adult social care to be open with patients when things go wrong and will be a requirement of the Trust’s registration with the Care Quality Commission (CQC). The CQC will monitor compliance with the Duty of Candour and will use its enforcement powers where the Trust fails to meet the registration requirement.

8.4 All Trust staff have a statutory obligation to observe Duty of Candour. This means that, if a member of staff believes or suspects that the patient suffered moderate harm or above as a result of an incident it is their duty to report this as an incident; to inform the service user and/or their carer as soon as possible; to apologise and to provide any information and explanation as may reasonably be requested. Staff should refer to the Trust’s Being Open Policy for further information and guidance about the Duty of Candour.

8.5 Staff whose professional regulatory body is either the General Medical Council

(GMC) or the Nursing and Midwifery Council (NMC) are reminded that the professional codes for doctors and nurses already require them to put the interests of the service user first and to be open and honest in dealing with service users and/or carers at all times.


9. Information Governance Incidents

9.1 A requirement from the Department of Health came into force on 1st June 2013 that

required all organisations processing health and social care personal data, to use the

IG Toolkit Incident Reporting Tool to report level 2 Information Governance Serious

Incidents Requiring Investigations to the Department of Health, The Information

Commissioners Office and other regulators. The Trust’s IG team uses the information

provided via DatixWeb to complete this if required.


PART II – ADDITIONAL RESPONSIBILITIES FOR MANAGERS, HANDLERS AND

SPECIALIST LEADS

10. Maintaining Safety

10.1 Managers are responsible for ensuring that action is taken promptly to contain the incident and to minimise harm. The manager will be informed immediately when an incident occurs. Managers must be fully familiar with the Trust policies that give guidance on action to be taken in the case of particular types of incident. (see section 19).

11. Reporting and Follow Up of Incidents

11.1 Managers will ensure that all staff are aware of how to report incidents online. 11.2 Following any incident, the manager will inspect the scene of the incident and

undertake a preliminary investigation as to how and why the incident occurred (except in instances where the police have taken over the investigation).

11.3 Where any incident report indicates that a service user, carer or member of the public

has made, or wishes to make, a complaint, the Manager will ensure that

the relevant person receives a copy of the Advice and Complaints Leaflet; an attempt is made to resolve any complaint locally; the person is given any necessary assistance in making a complaint, including

referral to Advice and Complaints Service, if appropriate. 11.4 Where an incident involves a service user who may not be aware of the occurrence

(for example in the case of a medication error) the service user will normally be informed of the incident by the manager or, following a briefing by the Manager, by another appropriate member of staff during the shift or span of duty in which the incident occurred, and documented on Trust electronic patient records Carenotes (in accordance with the Being Open and Duty of Candour Policy). If there are particular circumstances which may make it inappropriate or impracticable for this information to be given to the service user at this time, the reasons for this will be documented on Carenotes and also forwarded to the Risk and Patient Safety Manager, who will determine what action should be taken to protect the service user’s rights and interests in relation to this information.

11.5 With the consent of the service user, information about any incident may also be

reported to relevant carers. This information may also be given to carers in the case of service users who lack capacity to consent, provided that it is in the best interests of the service user for this information to be given. The Trust’s Information Governance Manager is able to give advice where required.

11.6 ‘Handlers’ and ‘Specialist Leads’ will ensure that they respond to all DatixWeb

incident reports in a timely manner and are advised to login to DatixWeb on a daily basis to review incidents within their area/s of responsibility.


11.7 ‘Handlers’ will review and signoff incidents for final approval on DatixWeb within 5 days of the incident being reported. Furthermore, ’Handlers’ will: acknowledge receipt of the incident to the reporter and any other staff involved; ensure there is a mechanism in place for regular follow-up discussions and

feedback to their teams on learning and actions taken arising from incidents; check, and amend if necessary, the accuracy of the incident details provided on

the online form; ensure the details of all those involved in the incident are recorded on the

online form; liaise with the ‘Specialist Lead(s)’ if necessary to ensure the appropriate follow-

up actions are taken to manage the incident correctly; record the outcome of their investigation, including follow-up actions taken, and

lessons learned; assess and record the actual degree of harm caused by the incident using the

‘Result’ and ‘Severity’ fields on the online form (see Appendix 2); apply a risk rating: every incident should be graded in terms of its ‘Likelihood’ of

recurrence and actual ‘Consequence’ (see Appendix 3); 11.8 ‘Specialist Leads’ will review incidents on DatixWeb within 5 days of the incident

being reported. Furthermore, ’Specialist Leads’ will: liaise with the ‘Handler’ to provide support and ensure the appropriate follow-up

actions are taken to manage the incident correctly; record the outcome of their investigation, including their recommendations and

follow-up actions taken; ensure there is a mechanism in place for regular follow-up discussions and

feedback to teams on learning arising from incidents within their specialist area; identify issues and training needs to be addressed within their specialist areas

through the monitoring of incident trends; 11.9 On occasions where the team manager is the person reporting an incident for their

team, they may allocate themselves as the ‘Handler’ and will also need to approve that incident on DatixWeb. However, if the team manager is directly involved in the incident they should allocate their line manager as the ‘Handler’ responsible for approving the incident on DatixWeb.

11.10 All managers and Specialist Leads will require a log in name and password for

DatixWeb, which can be obtained from the Governance & Quality Assurance Department (see contact details in Appendix 6).

11.11 For guidance on how to record investigations and signoff incidents for final approval on DatixWeb see Appendix 6.

12. Service Managers 12.1 Service Managers will be able to view online incident reports relating to the teams

they manage at any time. They will require a log in name and password, which can be obtained from the Governance & Quality Assurance Department (see contact details in Appendix 6).

It is recommended that Service Managers view the incidents within their area/s of

responsibility on a least a weekly basis.


12.2 On viewing an incident report the Service Manager will liaise with the manager and take any necessary steps to investigate the circumstances and causes of the incident if required. Managers are encouraged to adopt a Root Cause Analysis approach in undertaking any investigation.

12.3 The Service Manager will then take appropriate steps to ensure that the causes of

the incident are addressed and will also report to the Risk & Patient Safety Manager any continuing hazard that has been identified during the investigation.

12.4 The Service Manager will ensure that the details of any investigation and its findings are recorded online by the ‘Handler’ on the DatixWeb incident form.

13. Governance & Quality Assurance Department

13.1 The Governance & Quality Assurance Department reviews all incidents reported via

DatixWeb, and where particular concerns are raised ensures the correct ‘Specialist

Leads’ have received email notification of the incidents for additional follow up and

information gathering (see section 18).

13.2 The Governance & Quality Assurance Department reviews all incidents with a

severity of Moderate or above for possible escalation and formal investigation as a

‘Serious Incident’ (See the Management of Serious Incident Policy).

13.3 The Governance & Quality Assurance Department reviews all Death incidents for

escalation and review under the Trust’s mortality review process (see Learning From

Deaths Policy)

13.4 The Governance & Quality Assurance Department will ensure processes are in place

for all additional, external reporting requirements to be adhered to (see section 19).

13.5 The Risk and Patient Safety Manager is available to provide advice in relation to

incident reporting, follow up and investigation. The Health and Safety Manager can

also be contacted to provide advice in relation to specific health and safety incidents

and to assist with or undertake health and safety investigations.

14. Additional Follow Up of Incidents 14.1 The manager investigating an incident will contact the Risk and Patient Safety

Manager if any further incident investigation reveals factors that suggest a need for additional analysis, audit, or inclusion on the Trust Risk Register.

14.2 If any further investigation identifies any safety lessons then these will be recorded on

the online incident form in DatixWeb and additionally circulated to all relevant teams in the Trust. The Risk and Patient Safety Manager or Health and Safety Manager will also liaise with any external stakeholders where appropriate.


14.3 Any recommendations or actions arising from an investigation will be monitored in the same way as for Serious Incidents (please refer to the Management of Serious Incidents Policy).

15. Timeframes for Incident Management

15.1 When an incident occurs, staff present will take immediate steps to contain the incident and to minimise harm.

15.2 The manager or the person in charge will be informed immediately. 15.3 All incidents will be reported online via DatixWeb as soon as is practicable, and

certainly within the same shift or span of duty. 15.4 All ‘Serious Incidents’ will be notified to the Governance & Quality Assurance

Department immediately (please refer to the Management of Serious Incidents Policy

for timeframes relating to Serious Incident Investigations). 15.5 Specialist Leads will review incidents and provide advice and support to Handlers as

soon as is practicable, and certainly within 5 days of the incident being reported.

15.6 Handlers will ensure incidents are investigated and signed off as soon as is

practicable, and certainly within 5 days of the incident being reported. 15.7 Handlers will feedback the outcome of the investigation to those involved in the

incident as soon as is practicable, and certainly within 5 days of the incident being signed off.

16. Support for Staff 16.1 Incidents (including serious incident), complaints and claims can affect members of

staff, causing physical and psychological harm. The Trust takes its responsibilities seriously for supporting staff in these circumstances. Managers are responsible for providing support to members of staff following an incident, complaint or claim; Service Managers must ensure that appropriate support is in place. For more details on advice and support for staff who have been involved in an incident see the Being Open and Duty of Candour Policy and the Trauma at Work Pathway document.

16.2 Immediate support

After an incident has occurred, the manager in charge at the time must ensure that staff involved in the incident are appropriately supported. This may include relieving staff of their immediate responsibilities, supporting them to seek medical or occupational health advice or accompanying them to give information to the police. If at all possible, DatixWeb incident report and initial statements about the incident should be completed before the member of staff goes off duty.

16.3 Ongoing support


At a suitable time, staff should be given the opportunity to talk through the incident with their manager or another senior member of staff. Managers should consider holding a debriefing session for the team or group of staff most closely connected with the incident. If a debriefing session is held, it should be well planned and facilitated by a senior member of staff. In the longer-term, staff should be supported in general terms by their line manager and formally through their supervision. If staff are asked to participate in an investigation into an incident, complaint, or claim, they should be provided with appropriate information about the process and what is required of them. Information about investigation processes, both internal and external, will be available from the investigating manager, the Local Security Management Specialist, the Health and Safety Manager and the Governance & Quality Assurance Department. Any staff involved in an incident, complaint or claim which is subject to an investigation must be informed about the outcome of that investigation and any recommendations made; managers are responsible for ensuring this happens.

16.4 Further action If members of staff experience difficulties associated with the incident, they may refer themselves or be referred by their manager at any point to Occupational Health (see section 18).

17. A Learning Culture 17.1 Managers will promote an open and fair culture within their team, to enable staff to be

confident in reporting incidents as they occur, and in which learning from incidents is actively encouraged.

17.2 Managers will ensure that their team reviews its own incidents and considers what

lessons should be learnt and whether additional actions should be taken. Managers can request further analysis of incident data and information from the Governance & Quality Assurance Department at any time. Managers of clinical teams will make arrangements for their team to regularly discuss and review incident data either directly accessed from DatixWeb or provided by the Governance & Quality Assurance Department, and will ensure any feedback is provided.

17.3 Specialist Leads are responsible for the analysis of incident data and the production of reports for groups and committees within their own specialist area. They will ensure issues and training needs to be addressed are identified through the regular monitoring of incident reports within their own specialist area.

17.4 The Risk and Patient Safety Manager is responsible for the analysis of incident data

and the production of reports for groups and committees on a regular basis. The Head of Governance and Quality Assurance is responsible for providing reports on serious incidents.

17.5 Aggregated incident data is reviewed and monitored on a regular basis in various

committees and groups across the Trust to ensure trends and frequencies are identified and addressed. The Quality Committee and Trust Board receive an


overview of all incidents reported, and a number of other committees and groups utilise incident information that is relevant to their specific needs.

17.6 In addition, the Risk Management Annual Report contains an aggregated analysis of

all incidents, complaints and claims. This report is received by both the Audit and Risk Committee and the Trust Board.

17.7 All groups and committees within the Trust’s governance structure have responsibility

for identifying potential risks as a result of their discussions, and for ensuring that action is taken to mitigate and reduce risk, as set out in the Trust’s Risk Management Strategy.

17.8 The Trust contributes to the NHS Improvement National Reporting and Learning

System in order to contribute to wider national learning around incidents that take place in Mental Health settings.


18. Responsibilities of Specialist Staff

A number of staff have specialist responsibilities in relation to incident reporting and follow up. These are detailed below:

Specialist Area Department or Position Contact Name Phone E-mail

Datix Manager Risk and Patient Safety Manager

Margaret O’Driscoll 020 3317 6564 [email protected]

Serious Incidents Risk and Patient Safety Manager

Kevin Cann 020 3317 7101 [email protected]

Mortality Review Risk and Patient Safety Manager

Samantha Barclay 020 3317 6560 [email protected]

Complaints / Inquests Complaints and Inquests Manager

Emma Francis 020 3317 3117 [email protected]

Health and Safety Health and Safety Manager David Hodgkinson 020 3317 7351 [email protected]

Occupational Health Occupational Health - People Asset Management Ltd (PAM)

People Asset Management Ltd (PAM)

020 3866 6600 [email protected]

Violence and Security Local Security Management Specialist

Lynn Taylor 020 3317 7079 [email protected]

Information Governance and Information Security

Interim Information Governance Manager

Gerard Kursten 020 3317 7100 [email protected]

Safeguarding Safeguarding Manager Alwyn Davies 020 3317 7096 [email protected]

Medicines Medicines Safety Officer Svetlana Jankovic 020 7561 4161 [email protected]

Infection Control Senior Infection Control Nurse Brid Fitzgerald 0203 317 7383 [email protected]

Medical Devices Medical Devices Liaison Officer Christina Amin 0203 317 7090 [email protected]

Estates and Facilities Assistant Director Estates and Facilities Project

Phil Wisson 020 3317 7352 [email protected]

Fraud Local Counter Fraud Specialist Karenjeet Basra 0746 836 7201 [email protected]

Major Incidents Head of Emergency Planning Response & Resilience

John Griffin 020 3317 7381 [email protected]

mailto:[email protected]








19. Reporting and Other Requirements for Incidents of Specific Types

All incidents will be reported online using the DatixWeb Incident Reporting Form as described above. For the types of incident detailed below, additional reporting requirements also apply, as summarised here.

19.1 Serious Incidents (StEIS)

Type of incident Reporting responsibilities and timescale

Information to be supplied:

(do not delay reporting if full information is not available)

Additional Action

Serious Incidents, including:

the unexpected or avoidable death of a service user, visitor, member of the public or member of staff;

permanent or significant harm to a service user, visitor, member of the public or member of staff;

a “never event”. Please see the Management of Serious Incidents Policy for an up-to-date list of “never events” as defined by the National Patient Safety Agency;

serious outbreak of infection;

serious data loss or breach of service users’ confidentiality;

significant failure in Safeguarding responsibilities;

serious damage to Trust property.

The manager (or another person with delegated responsibility) should report the incident to the Risk and Patient Safety Manager immediately by phone (020 3317 7101)

The Manager should ensure a DatixWeb incident report is completed within the shift in which incident occurred.

The Risk and Patient Safety Manager will report the incident on StEIS (Strategic Executive Information System), within one working day of the incident being confirmed as meeting the threshold for a serious incident investigation.

Service User Details where relevant: Local ID, full name, date of birth, ethnicity, MHA status, Date of Death (if applicable)

Incident Details: Date, time, location, persons and buildings/assets involved details of any injury. Names (and job titles where appropriate) of witnesses.

Name of Consultant: (or, where there is no consultant, professional primarily responsible for treatment in the Trust).

Contact name and details for further inquiries.

As required by the nature of the incident (see other reporting requirements in this section)

Follow the Management of Serious Incident Policy


19.2 Medical Devices (MHRA)

Type of incident Reporting Responsibilities and timescale



Additional Action

Incidents involving medical devices

Includes incidents arising due to shortcomings in:

the device itself;

instructions for use;

servicing and maintenance;

locally initiated modifications or adjustments;

device-user practices, including training;

management procedures;

conditions of use/environmental conditions (e.g. electromagnetic interference);

location (e.g. devices designed for use in hospital may not be suitable for use in the community).


The Medical Devices Lead will report the incident to the Medicines and Healthcare products Regulatory Agency (MHRA) if required

Contact name and details for further inquiries;

Date and time of the incident;

Details of any injury caused by the defective device;

To whom did the injury occur;

Details of treatment required;

Consultant in charge of treatment provided;

Details of incident or defect and local action taken.

Ensure that the ‘Medical Devices’ section of the DatixWeb Incident Reporting Form is complete prior to submission. This includes:

generic type, brand name, model and size of device;

serial/product and batch/lot numbers;

manufacturer/supplier;

whether the device bears a 'CE' marking;

date of manufacture;

date that the device was put into use;

quantity of devices which are defective;

Location of device now.

In all cases: Withdraw device from use and retain it for inspection. Do not interfere with it in any way, except for safety reasons or to prevent its loss. Quarantine it, along with associated disposables and contact the Medical Physics Department

Small equipment: label and keep secure together with any packaging material or other means of batch identification.

Large equipment: contact Estates and Facilities Department for advice on removal/storage etc.

Recording devices: Where applicable, make a record of all readings, settings, positions of switches, values etc. together with any photographic evidence of the fault.

Follow the Medical Devices Policy


19.3 RIDDOR - Reports of Incidents and Dangerous Disease Occurrences Regulations 1995 (HSE)

Type of incident Reporting responsibilites and timescale Information to be supplied:


Additional Action

Work Related Disease

Any instance where a staff member has been notified by their doctor that they suffer from a reportable work-related disease.

Manager/Staff Member should inform Occupational Health, on the day in which the information becomes confirmed.

The Manager should report the incident to the Health and Safety Manager on the day in which the information becomes confirmed.

Manager/Staff Member should ensure a DatixWeb incident report is completed as soon as possible after the information has been confirmed.

Incident will be reported to the HSE under RIDDOR by the Health and Safety Manager.

Name, place of work and contact details of staff member

Details of illness

Contact details of reporting doctor.

As required by the nature of the incident (see other reporting requirements in this section)

As advised by Occupational Health

Follow the Absence Policy if applicable

Follow the Health and Safety Policy

See Health and Safety Executive (HSE) Website: http://www.hse.gov.uk/riddor/

Staff absence as a result of an incident which may need to be reported under RIDDOR

Any injury or psychological harm which results in a person being unable to do their normal work for more than seven days (whether or not scheduled to work)


Manager should report to the Health and Safety Manager, as soon as the 7th day of absence is confirmed.


The following information if not included on DatixWeb Incident Reporting Form

Home address of any injured person

Age of any injured person

Where incident occurred

Normal activity of the premises

If the injured person fell from a height, what distance they fell.

Details of what happened and how.

Action following the

http://www.hse.gov.uk/riddor/


Incidents which may need to be reported under RIDDOR

Work related injuries resulting in:

Death

fractures or dislocations·

eye injuries

unconsciousness

admittance to hospital for more than 24 hours;

acute illness

Dangerous occurrences:

failure of load-bearing equipment, lifts, hoists, etc.

collapse of any part of a building

explosions

incidents involving electrical power lines; electrical overload, or electrical fire

fire causing suspension of normal work for over 24 hours;

burst pipes

accidental release of flammable liquids or any substance which may damage health

The Manager should ensure a DatixWeb incident report is completed within the shift in which incident occurred (or result of injury is established if this is not immediately known)


incident, including details of the action/advice provided to injured person e.g. sent to A&E, first aid provided on site, saw their own GP (as applicable). Dates of any Occupational Health appointments etc., expected date of return to work (if known.)

If the incident relates to manual handling, provide details of the training the injured person has received over the last two years.


19.4 Patient Safety Incidents (NHS Improvement)

Type of incident Reporting responsibilities and timescale



Additional Action

Incidents that affect, or could affect the safety of service users are reported routinely to NHS Improvement via their ‘National Reporting and Learning System’.

The Manager should ensure a DatixWeb incident report is completed within the shift in which incident occurred

The Incident Reporting Officer must upload all Patient Safety Incidents to NHS Improvement every 2 weeks or at least monthly.

Details completed as requested on the DatixWeb Incident Reporting Form.

As required by the nature of the incident (see other reporting requirements in this section);

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20. Dissemination and implementation arrangements

20.1 The Policy is posted on the Trust Intranet where all staff can access it. 20.2 Associate Divisional Directors, Service Managers and Team Managers, will be notified of

updates to the policy, and will brief the staff they manage. 20.3 The Risk and Patient Safety Manager can be contacted for clarification support in the

implementation of the policy on 020 3317 6564. 20.4 This document will also be made available to other stakeholders and to service users or

members of the public on request.

21. Training requirements

21.1 For training requirements please refer to the Trust’s Core Skills Training Policy on the Trust

Intranet (https://intranet.candi.nhs.uk/policy/overview/1090/core-skills-training).

21.2 An overview of the procedure for incident reporting will be delivered to all staff as part of the Trust’s Corporate Induction programme.

21.3 The Governance & Quality Assurance Department will provide training for Managers on the procedure for incident reporting and management on a twice yearly basis, or on an ad-hoc basis via 1:1 sessions and the Datix helpdesk.

21.4 Managers will ensure that all staff within their department or team are familiar with this

procedure and have been given guidance on the process for reporting incidents (see Appendix 4 and Appendix 5).

21.5 Managers will ensure that temporary or agency staff are given guidance on the need to

report incidents and the procedure for doing so, as part of their local induction (see Appendix 4 and Appendix 5).

21.6 Managers will ensure that any person whom they may delegate to take charge of the Team

or Department is familiar with the requirements within this policy.

22. Monitoring and audit arrangements 22.1 The implementation of this policy will be monitored by the following:

Incident Reporting rates (NRLS data) Timeliness of reporting (Quarterly Divisional Performance Meetings) Timeliness of incident signoff (Quarterly Divisional Performance Meetings) Quality Committee and Trust Board review of monthly/quarterly incident data

23. Review of the policy

23.1 The policy will be due for review in April 2021 or earlier should a new directive or change in

practice became evident.

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23. References

A guide to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

1995 L73 (Third edition) HSE Books 2008 ISBN 978 0 7176 6290 6

Department of Health (2001). Building a Safer NHS for Patients: Implementing an Organisation with a Memory. London: HMSO.

Department of Health (2011). The “Never Events” List 2011/12. Policy Framework for use in the NHS. London: HMSO.

Equipped to Care. The Safe Use of Medical Devices in the 21st Century. MDA. Crown Copyright 2000. ISBN: 1 84182 170 5.

National Patient Safety Agency (2004). Seven Steps to Patient Safety; The Full Reference Guide, second print. National Patient Safety Agency, London.

National Patient Safety Agency (2008). Seven Steps to Patient Safety in Mental Health. National Patient Safety Agency, London.

The Health and Safety at Work etc. Act 1974 (c. 37)

25. Associated documents

Management of Serious Incidents Policy

Learning From Deaths Policy

Being Open and Duty of Candour Policy

Health and Safety Policy

Trauma at Work Pathway

Raising Concerns at Work Policy

Complaints Policy

Claims Policy

Information Governance Policy

Medical Devices Policy

Security Management Policy

Risk Management Strategy

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APPENDIX 1

INCIDENT TRIGGER LIST SUMMARY Below is a list of events which should trigger an incident report via DatixWeb. This list is not exhaustive and is intended only as an example of the types of event that would be considered an ‘Incident’. Any event or circumstance that could have led to or did lead to a patient, a member of the public, or a member of staff experiencing unintended, unwanted or unexpected harm is considered an ‘Incident’ and should be reported. Non-clinical incidents should also be reported such as impact on business continuity, Fire, Health and Safety etc. If in doubt report it!

1. Accidents

2. Attempts to Abscond

3. Verbal Aggression (including racial harassment)

4. Physical Aggression

5. Sexually Inappropriate Behaviour (including harassment)

6. Allegations of abuse

7. Breach of Confidentiality

8. Estates failure / building damage

9. Falls

10. Fire

11. Hostage situation

12. Inappropriate behaviour e.g. consenting to sex

13. Infection control risk / ill health

14. Loss/theft/security/fraud

15. Medication errors/Medication under restraint

16. Mental Health Act Law

17. Missing from Care (including Absent Without Leave (AWOL))

18. Inappropriate patient discharge (early or self discharge)

19. Possession of an offensive weapon

20. Safeguarding concerns

21. Self-harm/Suicide

22. Substance abuse (alcohol and drug)

23. Unaccounted for loss or injury

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Degree of harm APPENDIX 2

As part of reviewing and singing off incidents for final approval Handlers must assess and record the degree of harm caused by the incident. Grading the degree of harm resulting from an incident can be a challenge, but the degree of harm should always reflect the ACTUAL impact as a result of the incident. The degree of harm is recorded using the ‘Result’ and ‘Severity’ fields on DatexWeb. When assessing the severity of the incident the following short definitions should be applied:

DatexWeb Description Definition

No Injury No actual harm caused

Minor Injury Low (Minimal harm - patient(s) required extra observation or minor treatment)

Moderate Injury Moderate (Short term harm - patient(s) required further treatment, or procedure)

Permanent Injury Severe (Permanent or long term harm)

Life-threatening Events or Death Death (Caused by a failure of care by C&I services)

Please note when recording incidents affecting Service Users:

Record the degree of actual harm caused to the service user as a direct consequence of a failure in care by C&I services. If the incident was not as a direct result of a failure in care by C&I services the Result is “No harm, injury or adverse outcome” and the Severity is “No injury” irrespective of the actual injury incurred. Typical examples of such incidents are deaths by natural causes or falls in the community - unless a failure in care by C&I services contributed to the incident the Result is “No harm, injury or adverse outcome” and the Severity is “No injury”.

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Guidance for Rating Risk APPENDIX 3 This grading guidance is taken from the National Patient Safety Agency document ‘A Matrix for Risk Managers’ (2008). STEP ONE: Severity - How severe are the consequences? Table 1: Severity / Impact Categories

Consequence score (severity levels) and examples of descriptors

1 2 3 4 5

Domains Negligible Minor Moderate Major Catastrophic

Impact on the safety of patients, staff or public (physical/ psychological harm)

Minimal injury requiring no/minimal intervention or treatment. No time off work

Minor injury or illness, requiring minor intervention Requiring time off work

for ˂3 days

Increase in length of hospital stay by 1-3 days

Moderate injury requiring professional intervention Requiring time off work for 4-14 days Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident An event which impacts on a small number of patients

Major injury leading to long-term incapacity/disability Requiring time off work for >14 days Increase in length of hospital stay by >15 days Mismanagement of patient care with long-term effects

Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients

Quality/complaints/ audit

Peripheral element of treatment or service suboptimal Informal complaint/inquiry

Overall treatment or service suboptimal Formal complaint (stage 1) Local resolution Single failure to meet internal standards Minor implications for patient safety if unresolved Reduced performance rating if unresolved

Treatment or service has significantly reduced effectiveness Formal complaint (stage 2) complaint Local resolution (with potential to go to independent review) Repeated failure to meet internal standards Major patient safety implications if findings are not acted on

Non-compliance with national standards with significant risk to patients if unresolved Multiple complaints/ independent review Low performance rating Critical report

Totally unacceptable level or quality of treatment/service Gross failure of patient safety if findings not acted on Inquest/ombudsman inquiry Gross failure to meet national standards

Human resources/ organisational development/staffing/ competence

Short-term low staffing level that temporarily reduces service quality (< 1 day)

Low staffing level that reduces the service quality

Late delivery of key objective/ service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale Poor staff attendance for mandatory/key training

Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Loss of key staff Very low staff morale No staff attending mandatory/ key training

Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff No staff attending mandatory training /key training on an ongoing basis

Statutory duty/ inspections No or minimal impact or breech of guidance/ statutory duty

Breech of statutory legislation Reduced performance rating if unresolved

Single breech in statutory duty Challenging external recommendations/ improvement notice

Enforcement action Multiple breeches in statutory duty Improvement notices Low performance rating Critical report

Multiple breeches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

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Adverse publicity/ reputation

Rumours

Potential for public concern

Local media coverage – short-term reduction in public confidence Elements of public expectation not being met

Local media coverage – long-term reduction in public confidence

National media coverage with <3 days service well below reasonable public expectation

National media coverage with >3 days service well below reasonable public expectation. MP concerned (questions in the House) Total loss of public confidence

Business objectives/ projects

Insignificant cost increase/ schedule slippage

<5 per cent over project budget Schedule slippage

5–10 per cent over project budget Schedule slippage

Non-compliance with national 10–25 per cent over project budget Schedule slippage Key objectives not met

Incident leading >25 per cent over project budget Schedule slippage Key objectives not met

Finance including claims Small loss Risk of claim remote

Loss of 0.1–0.25 per cent of budget Claim less than £10,000

Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000

Uncertain delivery of key objective/Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million Purchasers failing to pay on time

Non-delivery of key objective/ Loss of >1 per cent of budget Failure to meet specification/ slippage Loss of contract / payment by results Claim(s) >£1 million

Service/business interruption Environmental impact

Loss/interruption of >1 hour Minimal or no impact on the environment

Loss/interruption of >8 hours Minor impact on environment

Loss/interruption of >1 day Moderate impact on environment

Loss/interruption of >1 week Major impact on environment

Permanent loss of service or facility Catastrophic impact on environment

STEP 2: Likelihood – How likely is it that the risk event will occur / reoccur?

Likelihood may need to be assessed in a different manner depending on the nature of risk. For example, the likelihood that a particular incident will occur in a particular team is best suited to a likelihood measure that is based on ‘frequency’ (Table 2). If, however, we look at the risks associated with visiting a service user at home, it is sensible to focus on the ‘probability’ that the risk will be actualised given existing controls that are in place (Table 3). It is for this reason that the measure of likelihood has been split into two tables, either of which may be used as appropriate. The Trust has decided to follow examples of good practice by using the two scales as below. TABLE 2: LIKELIHOOD / FREQUENCY SCALE

Likelihood score 1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost certain

Frequency

Not expected to occur for years.

Expected to occur at least annually.

Expected to occur at least monthly.

Expected to occur at least weekly

Expected to occur at least daily

Table 3: Likelihood / Probability Scale

Likelihood score 1 2 3 4 5

Descriptor Rare Unlikely Possible Likely Almost certain

Frequency

This will probably never happen/recur

Do not expect it to happen/recur but it is possible it may do so

Might happen or recur occasionally

Will probably happen/recur but it is not a persisting issue

Will undoubtedly happen/recur, possibly frequently

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STEP 3: The Risk Matrix (Likelihood x Consequence) - In order to calculate the risk score, the ‘likelihood’ is multiplied by the ‘severity/impact’ using the matrix in Table 4.

Table 4: The Risk Matrix

Likelihood

Consequence 1 2 3 4 5

Rare Unlikely Possible Likely Almost certain

5 Catastrophic 5 10 15 20 25

4 Major 4 8 12 16 20

3 Moderate 3 6 9 12 15

2 Minor 2 4 6 8 10

1 Negligible 1 2 3 4 5

For grading risk, the scores obtained from the risk matrix are assigned grades as follows:

1 - 3 Low risk

4 - 6 Moderate risk

8 - 12 High risk

15 - 25 Extreme risk

STEP 5: Risk Treatment – Decide on a course of action which is relative to the level of risk.

Risk Rating Degree of Risk Action required to reduce the risk

(1-3) Low A risk at this level may be acceptable. If not acceptable, existing controls should be monitored or adjusted. No further action or additional controls are required.

(4-6) Moderate Not normally acceptable. Efforts should be made to reduce the risk, provided this is not disproportionate. Establish more precisely the likelihood of harm as a basis for determining the need for improved control measures.

(8-12) Significant Very unlikely to be acceptable. Significant resources may have to be allocated to reduce the risk. Where the risk involves work in progress urgent action should be taken.

(15 - 25) High Unacceptable. Immediate action must be taken to manage the risk. Control measures should be put into place which will have the effect of reducing the impact of an event or the likelihood of an event occurring. A number of control measures may be required.

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APPENDIX 4

Grading of Incidents using the NPSA Risk Rating Matrix Incidents should be graded as follows:

DATIX Severity Field

National Patient Safety Agency Risk Rating Matrix

1 No Injury

Minimal injury requiring no/minimal intervention or treatment. No time off work required.

2 Minor Injury Minor injury or illness requiring minor intervention. Requiring time off work for <3 days. Increase in length of hospital stay by 1-3 days.

3 Moderate Injury Moderate injury requiring professional intervention. Requiring time off work for 4-14 days. Increase in length of hospital stay by 4-15 days RIDDOR/agency reportable incident. An event which impacts on a small number of patients

4 Permanent Injury

Major injury leading to long-term incapacity/ disability. Requiring time off work for >14 days. Increase in length of hospital stay by >15 days. Mismanagement of patient care with long-term effects

5 Life-threatening events or Death

Incident leading to death Multiple permanent injuries or irreversible health effects. An event that impacts on a large number of patients.

Further information can be found in the Incident Reporting Policy and Management of Serious Incidents Policy available on the Trust intranet.

SIX STEPS TO REPORTING

1. Ensure the safety of the patient, the staff and the environment. Summon help to assist you in dealing with the immediate situation

2. All incidents/near misses, regardless of the severity, should be reported

Remember – IF IN DOUBT REPORT IT 3. Complete an incident form on Datix as soon as possible after the event. Be factual in the description and record all that were involved, dates and times.

4. The Incident should be graded using the grading matrix. An incident that is deemed a Serious Incident (the actual harm caused is severe or death) should be reported IMMEDIATELY to your Associate Divisional Director and the Risk Management Team.

5. Co-ordination of the incident response is the responsibility of the most senior member of staff present to ensure that the incident is managed and investigated appropriately.

6. Following an Incident Investigation, any identified lessons learnt should be acted upon. An action plan should be developed to ensure that any changes necessary are also implemented. Lessons learned can then be shared.

RISK MANAGEMENT CONTACTS

Name and Contact Details Responsible for:

Gail Beggs Incident Reporting Officer Tel: 020 3317 7104

General Datix Queries

Samantha Barclay Risk & Patient Safety Manager Tel: 020 3317 6560

Serious Incident Queries/Notifications

Laura McMurray Risk & Patient Safety Manager Tel: 020 3317 7101

Mortality Review Queries/Notifications

INCIDENT REPORTING

GUIDE

Remember

IF IN DOUBT REPORT IT!

Risk Management January 2018

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What is an Incident?

Any event or circumstance that could have led or did lead to a patient, a member of the public, or a member of staff experiencing unintended, unwanted or unexpected harm. Non-clinical incidents should also be reported such as impact on business continuity, Fire, Health and Safety etc.

How do I report an incident?

Anyone can report an incident. All incidents are reported using the Datix system, an electronic database which is accessed via the Trust Intranet. All staff can report an incident - you do not need a log in account.

As a reporter of an incident you will need to consider the following information

Was a member of staff or patient affected?

You will need the patient’s details to complete the Datix so have these available.

Is the incident a clinical or non-clinical incident?

Was any harm caused?

Immediate action taken at time of incident

Facts about the incident such as: incident date and time, category of incident etc…

How do I get onto Datix?

The Incident reporting link is found on the front page of the intranet under QUICK LINKS.

How much information is required?

In the incident description box state what happened, use facts and not emotions. Names of staff or patients are not to be used in any free text boxes as this information

must be ANONYMISED. Names should be recorded in the contacts section where they are more secure.

Ensure all the fields have been completed, including, patient contact details and any specialist fields e.g. falls, medication, CPR, restraints, emergency services.

Ensure the correct “Handler” to investigate the incident has been chosen – this will nearly always be your team manager.

Ensure that you have checked your spelling.

Ensure that when you complete your own details you only use your Candi email address. e.g. [email protected]

How do I grade an incident?

The severity of an incident should be graded using the NPSA Risk Assessment Matrix according to the actual level of harm caused. The level of further investigation will be dependent upon the incident grading. There is always scope to re-grade the incident as further facts emerge and you can check that your grading is appropriate via the Risk Management Team.

An incident that is deemed a Serious Incident (the actual harm caused is severe or death) should be reported IMMEDIATELY to your Associate Divisional Director and the Risk Management Team.

What happens when I report an incident?

You will receive an automated e-mail to acknowledge the incident, providing details of the incident and a reference number. If you do not receive this then please contact the Incident Reporting Officer.

The Handler will receive an automated e-mail to notify them of the incident. They will look into the incident and consider if the details are complete and accurate, if the grading and severity are correct and may ask you for further information on what happened.

Feedback is an important part of learning from incidents and is provided by the Handler. They should let you

know the outcome of the investigation. If you do not received this then contact Risk Management Team and they will follow this up on your behalf.

What if this is not an incident and has been reported in error?

Don’t worry! The Handler will review the incident and can close it down with the help of the Risk Management Team if it is not considered an incident. Remember, IF IN DOUBT REPORT IT.

Informing patients, relatives or carers about the incident (Duty of Candour)

Information about an incident where a patient has suffered harm must be given to the patient and or their carers in a truthful and open manner by an appropriate person and follow the Being Open principles. Contact must be made as soon as possible following the incident. Where the patient lacks capacity to make decisions about their care, or has died, this contact should be with the person’s next of kin. Patients and carers should be given details of a named contact within the clinical team.

The Trust has an obligation to meet certain requirements under Duty of Candour, including: offering an apology; offering patients /carers an opportunity to be engaged in the incident review process; informing patients/carers about the outcome of the incident review process.

Further information can be obtained from Being Open and Duty of Candour Policy on the Trust intranet.

What is the time scale for investigating incidents?

All incidents should have an initial assessment by the Handler within 10 working days. Depending on the grade of the incident this maybe sooner - the Risk Management Team may request a Preliminary Review for deaths, or incidents with a harm level of Moderate or above, to be completed within 72 hours.

The timescale for completing Serious Incident investigations is 60 working days.

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APPENDIX 5

Datix Incident Form (DIF1) User Guide

This is the person most affected by the incident. Was it a service user, visitor, or a member of staff? If no person was involved, but there was a theft or damage to property, then click ‘affecting/potentially affecting the Trust’.

This is the precise location at which the incident occurred.

This is the date and time (24 hour clock) the incident took place.

Select the Division the incident occurred in. If you do not know your division, ask your line manager.

Select the Team the

incident occurred at. Select the Service delivered at the site where the incident occurred.

Select the Site where the incident occurred.

To open the form, The Incident reporting link can be found on the front page of the intranet under QUICK LINKS.

Was a service user or any other person such as staff, visitor or the

public involved?*

* If you choose YES a box will open for you to list the details of the people involved. You should record the details of any injuries sustained by those involved in this section also

Record details of Service Users in this section

Use this button to record the details of additional Service Users involved

Record details of Staff or others involved in this section

Use this button to record the details of additional Staff or others involved

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Enter just the facts about what happened and not opinions about the incident. DO NOT use people’s names or

initials.

This is the action taken at time of the incident, such as ‘first aid given’, or ‘service user counselled and removed from area’. DO NOT use people’s names or initials.

Select the Category of

incident.

This part of the form is for you to record who you are and what your contact details are. This is so you can be contacted if further clarification is needed at a later date and so feedback on the incident can be

provided to you.

Select the Subcategory of

incident.

Select Yes If the Service User was restrained during or after the incident. You will be asked to provide further details about the restraint.

Select Yes If the Emergency Services were called. You will be asked to provide further information about the Emergency Services

Record the degree of actual harm caused. If a service user is harmed record only the actual harm caused as a direct consequence of a failure in care by C&I services. If a service user was

affected but the incident was not as a direct result of a failure in care by C&I services the Result is “No harm, injury or adverse outcome” irrespective of the actual injury incurred.

If a service user was affected but the incident was not as a direct result of a failure in care by C&I services the Severity is “No injury” irrespective of the actual injury incurred.

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You are now ready to submit the form. The system will check you have filled in all the necessary fields, and if you have missed one, you will get a message to tell you which it is. You can only submit the form once all the mandatory fields have been completed. Once you click SUBMIT, the incident will be sent to the

Handler for approval.

Select the ‘Handler’ who will be responsible for investigating the incident and sending you feedback. In most cases this will be your line manager who will liaise with Specialist Leads (if necessary). If your line manager does not appear on the list please contact the Incident Reporting Officer

For further information and support contact: Incident Reporting Officer

Governance & Quality Assurance Department Tel: 020 3317 7104 (Office hours only) or email: [email protected]


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APPENDIX 6

Datix Investigation Guide For Handlers and Specialist Leads

Online User-Guide

(DIF2)

For further information and support contact: Incident Reporting Officer

Governance & Quality Assurance Department Tel: 020 3317 7104 (Office hours only) or email: [email protected]

What MUST a Handler do? 1. Review the incident ensuring it is a clear and accurate

account of the facts, amending if necessary.

2. Liaise with any Specialist Leads for expert advice and support where necessary.

3. Provide feedback directly to the incident reporter.

4. Record all action taken and any lessons learned.

5. Signoff the incident once their review is complete.

What MUST a Specialist Lead do? 1. Review the incident.

2. Liaise with the Handler to provide support and follow-up to the team or reporter.

3. Record their input and recommendations.


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Datix Investigation Guide for Handlers and Specialist Leads

Responsibilities for Handlers:

When a member of staff completes an incident form using DatixWeb, they must choose a person responsible for investigating this incident. This person is usually their manager or the person in charge of the team where the incident occurred. Datix calls this person the Handler. An email is automatically

generated and sent to the Handler informing them of the incident.

All reported incidents must be reviewed by the Handler. Once the Handler is satisfied the incident has been properly investigated, actions are in place to deal with the incident and these actions are properly

documented, the Handler must send the incident for final approval.

The assigned Handler must complete their review of the incident within 5 days of the incident being

reported. After this time the incident will be logged as overdue, the Handler will receive reminders from the Datix system. Overdue incidents are reviewed monthly at divisional performance meetings.

Responsibilities for Specialist Leads:

When a member of staff completes an incident form using DatixWeb, they must classify the incident using a number of drop down options on the reporting form. Depending on the options chosen individuals in the

organisation who have a specialist responsibility for that type of incident will automatically be notified by email that the incident has occurred. Datix calls these people Specialist Leads.

An example of some of the Specialist Lead roles in the Trust are listed below:

Health & Safety Manager Fire Officer

Local Security Management Specialist

Safeguarding Manager Falls Matron

PMVA Lead Nurse

Medical Devices Lead Nurse Infection Control Lead Nurse

Medicines Management and Dual Diagnoses Lead Nurse

Information Governance Manager ICT Clinical Safety Lead

Individuals or departments other than those listed above may also input to Datix as a Specialist Lead depending on the type and circumstances of the incident reported.

Logging into Datix:

Any member of staff can report an incident using the online Datix reporting form. The Incident reporting link is found on the front page of the intranet under QUICK LINKS.

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Handlers and Specialist Leads require a Datix account to login in order to review, update and in the

case of the Handler, send the incident for final approval following their investigation.

Users can login to Datix using the same link above by clicking on the Login link in the top left corner of the incident reporting form:

Users can also login to Datix by clicking on the link at the bottom of any incident email notification. If you

login via this method you will be taken straight to the incident (pg.5 Reviewing Incidents)

Navigating Incidents

When you login you will be presented with the following screen:

Options

My reports – here you will find custom reports that are already built into the system.

Design a report – here you can design your own reports using a variety of queries and custom report templates.

New search – here you can search for an individual incident (using the DW reference number) or group of incidents (using a query of your own design). NOTE: you will only be able to view

incidents that your profile permits. Saved queries – If you have saved any of your previous searches as a saved query you will be able

to access it here.

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Status

In holding area, awaiting review – This relates to newly reported incidents which are awaiting review and completion of their compulsory fields by the Handler and Specialist Lead(s) (if required).

Being reviewed – This relates to incidents which have been reviewed but have not been completed by the Handler and/or Specialist Lead.

Awaiting final approval – This relates to incidents where the Handler has reviewed the incident, completed the investigation with input from the Specialist Lead(s) (if required) and has sent the

incident for final approval. The Risk Management Team will provide final review and approval. Finally approved – Any incident that has been reviewed and approved by the Risk Management

Team will sit in this area. Rejected – Only the Risk Management Team can reject an incident. If as a Handler or Specialist

Lead you feel an incident form does not constitute an incident or near miss OR the incidents is a duplicate OR for any other reason, please contact the Incident Reporting Officer.

NB: The system is set to a timeframe of 5 days for reviewing of incidents and moving to status ‘Awaiting Final Approval’. After 5 days it is marked ‘overdue’ and a message is sent to the Risk Management Team.

If you are off sick or going on leave you must inform the Incident Reporting Officer and nominate another person to review and approve your incidents.

Handlers & Specialist leads are advised to login to Datix on a daily basis to review incidents within their area(s) of responsibility.

If you find that an incident has been wrongly assigned to you then you can have the incident reassigned to the correct person. To have the incident reassigned go to the email alert you received regarding the incident and click on reply. State that you are not the appropriate person to review the incident (if you

know the name of the person who is then this is useful information) and send. These emails are picked up by the Incident Reporting Officer who will then reassign the incident.

Opening an Incident

Click on the record number next to the appropriate status link to see the list of incidents in that group:

You will be presented with a summarised list of incidents. Incidents in this list can be sorted by clicking on the heading of the column you wish to sort by (clicking more than once reverses the order). To view a specific incident click on any descriptive field within this table, you will now have access to all details of the

reported incident.

If you click here you will see only the 6

overdue incidents In holding area, awaiting review

If you click here you will see all 12 incidents In holding area, awaiting review (including 6 overdue)

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To return to your selected list click on List Search Results which can be found on the left hand menu of most screens, or click on Incidents from the main menu which can be found at the top of every screen.

Reviewing Incidents

Information about the incident is grouped into a number of different panels to help you navigate the

details. These panels are listed on the left hand side of the form. Click on a title to be taken to this section of the incident form.

The first four panels are standard for all incidents. Further information may also be found in the remaining

category sections of the form depending on the incident classification.

The Handler must review the information reported and ensure the details are an accurate reflection of the

incident, editing the incident where necessary, and that all necessary information has been recorded. Any information that was omitted by the reporter must be filled in by the Handler.

Specialist Leads should review the sections of the form relevant to their specialist area and ensure the

details are accurately recorded, following up by liaising with the Handler and/or reporter if necessary and also amending the record where necessary.

Sections 1 - 4:

It is suggested that you review section 1-3 and any relevant category sections, and then complete section 4.

1. Name and reference – in this panel you will find, among other details, the unique DW reference number and the name of the Handler. This is also where the Handler will change the approval status of the incident to reflect where the incident is in the review process. Once the review has

been complete the Handler must change this status to Awaiting Final Approval

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2. Incident details – this section displays the detailed description of the incident as well as the incident classification. It also contains the specific details related to the team reporting and the

location of the incident.

3. Person(s) involved – this section lists everyone who was involved when the incident occurred, providing information about both service users and staff members. If any injuries were sustained by

those involved in the incident they will be found in this section.

4. Investigation:

a. This is where the Handler will record the outcome of their investigation (action taken and lessons learned). In this section the Handler must also review the Degree of Harm recorded by the reporter to ensure it is an accurate reflection of the actual harm caused - the Result

and Severity fields should only reflect harm suffered as a direct consequence of failure in care by Trust services.

b. This is where the Specialist Lead will record their comments or recommendations

(Specialist Leads comment(s)/recommendation(s)) – It is suggested the Handler and Specialist Lead liaise with each other where necessary. Select ‘save’ to finish.

Once section 4 Investigation is completed, the Handler should return to section 1 Name & reference and

send the incident for final approval by selecting Awaiting final approval. The final step is to click ‘save’.

The person MOST affected or if incident relates to Trust

e.g. equipment, please state equipment in the field.

The Handler is the person responsible for investigating

the incident and sending feedback to the reporter.

Once the review is complete change this status to

Awaiting Final Approval

To be completed by the Specialist Lead

To be completed by the Handler

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Category sections:

The following sections: Duty of Candour

Medical Emergency Form Medication

Equipment

Slip, Trips, Falls & Collisions Restraints recording

Emergency services

Misconduct NHSP

Will only contain data if the relevant to the incident classification e.g. if the incident category is Medicine the ‘Medication (read only)’ section will provide further detail regarding the incident. These sections should

also be reviewed by the Handler and Specialist Lead before signing off the incident.

Communications section:

Notifications – This section lists all persons who have been informed of the incident.

Communication and feedback – if you need to, you can send an email via Datix to any party that

may have some involvement within this specific incident. It can be for further clarification around the incident itself or if information is missing. By emailing via the incident itself an audit trail can

commence allowing other users with access to the incident to see all communication initiated.

Menu, Save & Cancel buttons:

On the left hand side of the screen there are a number of menu items that help you navigate the system

and are visible from most screens.

In addition there are three floating icons: Menu, Save and Cancel. For convenience these buttons float up and down the form on the left hand side as you scroll the various fields.

Menu – this option will show you a list of the section headings to allow you to go directly to any

section selected. Save – this will save the form. If you have not completed a compulsory field an alert will appear.

Cancel – Will take you out of the incident without saving any changes you have made.

Menu Save Cancel

DIF1 values are the original details

submitted by the reporter

Audit trail shows you any changes that

have been made since initially reported.

Takes you back to the list of incidents

returned in your most recent search.

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Documents

INCIDENT REPORTING POLICY JUNE 2019 Reporting Policy... · INCIDENT REPORTING POLICY_RM03_JUNE 2019 ii Contents Page POLICY SUMMARY FOR STAFF 1 Introduction 1 2 Aims and objectives