Incident reporting policy - Homerton University Hospital
Incident reporting policy - Homerton University Hospital Incident reporting policy - Homerton University Hospital
Level of Incident Process Investigation Investigation TeamLeadthat it is not an SUI, then a decision may bemade to conduct a Serious IncidentInvestigation (SII) that mirrors that of an SUI.Both SUIs and SIIs should be categorised assuch on Datix.•where the incident occurred]Two members of staff – fromthe staff group involved in theincidentAll Red SUI‟s and SII‟s should beinvestigated using Root Cause Analysis(RCA) methodology. Root Cause Analysis e-learning programme is available on NationalPatient Safety Agency‟s website atwww.npsa.nhs.uk/health/resources/root_cause_analysis for guidance on how to conduct aRCA.It is the responsibility of the relevant service /senior manager where the incident occurredto ensure that all learning points and safetyimprovements are appropriately identifiedand action plans drawn up, implemented,monitored and reviewed.Amber Incidents -ModerateConsideration should be given for conducting • Executive • Director Senior Managera root cause analysis investigation. It is theresponsibility of the relevant service managerwhere the incident occurred to ensure that all• Department / ServiceManager (from where theincident occurred)learning points and safety improvements areappropriately identified and action plansdrawn up, implemented, monitored andreviewed• A member of staff trained inRoot Cause Analysis (RCA)[ideally should not be fromthe service where theincident occurred]• Two members of staff – fromthe staff group involved inthe incidentYellow Incidents –MinorThe local team should identify learning pointsor safety improvements and implementcontrol measures.Any controls identified which are not withinthe local team's control should becommunicated to more senior managers forconsideration.GeneralManager/AssistantGeneralManager/Departmental ManagerHead ofNursing/LeadNurseDepartment / Ward / LineManager (from where theincident occurred)Two – three members of staff– from within the departmentGreen Incidents -Insignificant Harm orNegligibleThese should normally be investigated andreviewed locally in the ward or department inwhich the event occurred.Ward / department / linemanager.The local team should identify learning pointsor safety improvements and implementcontrol measures.Any controls identified which are not withinthe local team's control should becommunicated to more senior managers forconsideration.15.4 Time ScalesPage 14 of 47
It is important that investigations are carried out expeditiously as delay can lead to a reduction in reliabilityof the memories of those concerned, anxiety on the part of those being investigated and dissatisfaction forthose who have raised the matter for investigation (see 22.0 for SUI/SII investigation timescales) .16.0 Support during InvestigationIncidents can be very distressing for all concerned. All those involved in the incident should be givensupport. Managers should ensure that staff feel supported throughout the incident investigation process,as being involved too may have traumatised them. This support may be immediate or ongoing in naturedepending upon the circumstances and individual needs of that member of staff. Employee HealthManagement Service may be used for counselling and stress management if required.16.1 Support for those involved in an investigationIt is essential that all investigations are conducted in a manner that is demonstrably supportive to thoseinvolved and in a fair blame atmosphere. The process should be seen as being about listening, learningand improving. This will include providing those who are being investigated with a full account of thereasons for the investigation, giving them a proper opportunity to talk to the Lead Investigating Officer andensuring that they are kept informed of progress. Also any findings of the investigation and response tothird parties must be shared with those whose actions are being investigated.Where the investigation arises from a clinical issue the findings and response must be shared with theclinician to ensure factual accuracy. For midwives, their own Supervisor of midwives should be informed.Those involved must also be informed of support services that are available to them. An employee of theTrust being asked to submit a written statement (See Policy on Writing a Witness Statement) has the rightto consult their own union or other representative prior to submitting a statement or being called in as awitness, but this should not delay the process by more than 5 working days.16.2 Support for the Investigating OfficerWhere an investigation is likely to be time consuming the appointing Executive Director should assist theInvestigating Officer in reprioritising his/her existing workload while the investigation is taking place. Wherethe Investigating Officer feels that the investigation might result in a recommendation for disciplinary actionhe/she should contact their HR Manager as soon as possible for advice and support. Investigating Officersshould seek the support of the Clinical Director for the locality if medical/staffing issues have beenidentified. If there are any reasonable concerns about the objectivity of the Clinical Director, such supportshould be sought from the Medical Director or nominated clinical representative.17.0 Communication17.1 Communication with the affected individual (including patients)Every effort must be made to inform the individual involved as soon as possible before any media contactis made and in line with the Trust‟s Being Open Policy.The individual will receive treatment, care and support, and be given full information on the incident,including the outcome of the investigation. If the individual is incapacitated then next of kin and orsignificant other, must be informed in lieu of the patient. Where the incident has led to death or seriousinjury, the individual‟s next of kin must be informed before any media contact is made. The Lead Directorwill be responsible for delegating these tasks where appropriate.17.2 Communication with many affected individualsIt is acknowledged that on occasion, particularly where many patients have been involved or the incidenthas come to light some months later, it may not be possible to inform the individuals affected prior to themedia becoming aware, although it will be the responsibility of the Lead Director to ensure every effort todo has been demonstrated.There may be circumstances where there are multiple enquiries needing to be responded to, or a complex,high profile incident needing well co-ordinated action planning and implementation. In these events hotlinearrangements will be implemented. Please see Procedural Guidance for the Establishing and Running of aInformation Helpline for further details on the Trust strategy for hotline arrangements.Page 15 of 47
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It is important that investigations are carried out expeditiously as delay can lead to a reduction in reliabilityof the memories of those concerned, anxiety on the part of those being investigated and dissatisfaction forthose who have raised the matter for investigation (see 22.0 for SUI/SII investigation timescales) .16.0 Support during Investigation<strong>Incident</strong>s can be very distressing for all concerned. All those involved in the incident should be givensupport. Managers should ensure that staff feel supported throughout the incident investigation process,as being involved too may have traumatised them. This support may be immediate or ongoing in naturedepending upon the circumstances and individual needs of that member of staff. Employee HealthManagement Service may be used for counselling and stress management if required.16.1 Support for those involved in an investigationIt is essential that all investigations are conducted in a manner that is demonstrably supportive to thoseinvolved and in a fair blame atmosphere. The process should be seen as being about listening, learningand improving. This will include providing those who are being investigated with a full account of thereasons for the investigation, giving them a proper opportunity to talk to the Lead Investigating Officer andensuring that they are kept informed of progress. Also any findings of the investigation and response tothird parties must be shared with those whose actions are being investigated.Where the investigation arises from a clinical issue the findings and response must be shared with theclinician to ensure factual accuracy. For midwives, their own Supervisor of midwives should be informed.Those involved must also be informed of support services that are available to them. An employee of theTrust being asked to submit a written statement (See Policy on Writing a Witness Statement) has the rightto consult their own union or other representative prior to submitting a statement or being called in as awitness, but this should not delay the process by more than 5 working days.16.2 Support for the Investigating OfficerWhere an investigation is likely to be time consuming the appointing Executive Director should assist theInvestigating Officer in reprioritising his/her existing workload while the investigation is taking place. Wherethe Investigating Officer feels that the investigation might result in a recommendation for disciplinary actionhe/she should contact their HR Manager as soon as possible for advice and support. Investigating Officersshould seek the support of the Clinical Director for the locality if medical/staffing issues have beenidentified. If there are any reasonable concerns about the objectivity of the Clinical Director, such supportshould be sought from the Medical Director or nominated clinical representative.17.0 Communication17.1 Communication with the affected individual (including patients)Every effort must be made to inform the individual involved as soon as possible before any media contactis made and in line with the Trust‟s Being Open Policy.The individual will receive treatment, care and support, and be given full information on the incident,including the outcome of the investigation. If the individual is incapacitated then next of kin and orsignificant other, must be informed in lieu of the patient. Where the incident has led to death or seriousinjury, the individual‟s next of kin must be informed before any media contact is made. The Lead Directorwill be responsible for delegating these tasks where appropriate.17.2 Communication with many affected individualsIt is acknowledged that on occasion, particularly where many patients have been involved or the incidenthas come to light some months later, it may not be possible to inform the individuals affected prior to themedia becoming aware, although it will be the responsibility of the Lead Director to ensure every effort todo has been demonstrated.There may be circumstances where there are multiple enquiries needing to be responded to, or a complex,high profile incident needing well co-ordinated action planning and implementation. In these events hotlinearrangements will be implemented. Please see Procedural Guidance for the Establishing and Running of aInformation Helpline for further details on the Trust strategy for hotline arrangements.Page 15 of 47
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