POLICY ON THE REPORTING AND MANAGEMENT OF INCIDENTS AND THE INVESTIGATION OF AND LEARNING FROM INCIDENTS, COMPLAINTS AND CLAIMS

Transcription

1 POLICY ON THE REPORTING AND MANAGEMENT OF INCIDENTS AND THE INVESTIGATION OF AND LEARNING FROM INCIDENTS, COMPLAINTS AND CLAIMS Responsible head of service: Lindsay Longfield, Head of Business Unit 2 Name of responsible committee: Name of author: Contact for further details: Version: 1.0 Supersedes: Date approved: 22 March 2010 Review due: 22 March 2013 Key words: Document type: clinical risk and governance sub-committee Helen Torevell, clinical risk manager, BACHS Helen Torevell, helen.torevell@bradford.nhs.uk BAtPCT Policy for the reporting and management of incidents, December 2008 BAtPCT Policy and procedure for the investigation of incidents, complaints and claims, December 2008 Incident, complaint, claim, reporting, report, investigation, learning, prism policy If you are using a printed copy of this document please be aware that it may not be the latest version. To view the latest version visit nww.bradford.nhs.uk/extranet/policies/pages/default.aspx NOTE: All policies remain valid until notification of an amended policy is placed on the intranet.

2 CONTENTS section topic page 1. Introduction 3 2. Key related documents 3 3. Scope 4 4. Definitions 4 5. Key roles and responsibilities 4 6. Managing an incident 5 7. Reporting an incident 6 8. Investigating incidents, complaints and claims who should investigate? the investigation process concurrent internal and external investigations access to confidential records professional issues and criminal acts safeguarding children and vulnerable adults timescales for investigations record keeping 9. Learning from incidents, complaints and claims learning from individual incidents, complaints and claims learning from the aggregation and analysis of incident, complaints and claims data Training and competency requirements Monitoring References 13 Appendix 1 Incident reporting form 14 Appendix 2 External reporting requirements 15 Appendix 3 Template action plan 17 Appendix 4 Equality impact assessment 18 Appendix 5 Summary of policy development and consultation 21 BACHS 2010 page 2 of 21

3 Introduction 1.1 It is important that incidents are reported and well managed so that harm is minimised, and effectively investigated so that lessons can be learned. It is equally important that incident data is aggregated and analysed and that lessons are learned to reduce the risk of recurrence. The same principles apply with respect to complaints and claims. 1.2 BACHS is committed to ensuring that appropriate structures and systems are in place to support this. This policy describes how incidents should be reported and incidents, complaints and claims investigated and key roles and responsibilities for ensuring that this happens. It also describes how incident, complaints and claims data is aggregated and analysed to determine themes, trends and priorities for improvement. 1.3 Information about the reporting and management of complaints and claims is presented in other policies (see section 2). 1.4 Compliance with this policy will ensure: a systematic and consistent approach to the management and investigation of incidents, complaints and claims that the causes of incidents, complaints and claims are identified so that lessons can be learned and shared that lessons learned influence future practice. 1.5 This policy is written in accordance with: NHSLA requirements (NHSLA 2009) NHS Standard for better health C1a (DH 2004) It is also written to fulfil the Trusts (NHSBA incorporating BACHS) legal and statutory obligation to record and report certain defined incidents including: Health & Safety at Work Act 1974 and also subsequent legislative requirements for reporting incidents. The reporting of Injuries, Diseases & Dangerous Occurrences Regulations (RIDDOR) 1995 requirements to report certain events, which arise out of or in connection with work 2. Key related documents BACHS Compliments, comments, concerns and complaints management policy, December 2009 NHSBA and BACHS Claims handling policy and procedure, December 2008 NHSBA Policy and procedure for the performance and management of serious untoward incidents and never events, February 2010 BACHS Being open policy, March 2010 BAtPCT Health and safety policy, January 2009 BACHS Whistleblowing policy, June 2008 NHSBA Risk management strategy, November 2009 NHSBA Health and Safety Policy BACHS 2010 page 3 of 21

4 3. Scope 3.1 This policy applies to all employees of BACHS and to those providing services to or on behalf of BACHS under the terms of a contract or service level agreement. It relates to all incidents, complaints and claims as defined in this and related policies. 3.2 For further information on the reporting, management and investigation of serious untoward incidents the reader is referred to the NHSBA Policy and procedure for the performance and management of serious untoward incidents and never events, February This policy does not cover the reporting of concerns by staff. For further information on this topic the reader is referred to the BACHS Whistleblowing policy. 4. Definitions 4.1 An incident may be defined as any event, untoward or unusual, which is a deviation from the normal pattern of activity or therapeutic well-being or smooth running of the workplace (eg health centre, department, client s home, etc.), which involves patients and/or staff and/or visitors, and which may adversely affect their health and/or safety and/or welfare then or later. 4.2 A serious untoward incident is defined as an incident where a patient, member of staff, or member of the public has suffered serious injury, major permanent harm, or unexpected death or where there is cluster/pattern of incidents or actions by NHS staff which have caused or are likely to cause significant public concern. 4.3 A near miss may be defined as any incident that did not lead to harm, but could have led to harm under different circumstances. 4.4 A complaint has been made when a service user, or someone acting on their behalf, raises concerns about services or staff. Complaints may be formal, which means they must be dealt with in accordance with NHS complaints regulations, or informal which allows a more flexible response. 4.5 A claim is defined as an allegation of negligence and/or demand for compensation made following an incident which is being pursued through legal processes. 5. Key roles and responsibilities 5.1 The chief operating officer has ultimate responsibility for the content and implementation of this policy. 5.2 Other officers in conjunction with the heads of service have specific responsibilities for promoting the implementation of this policy in relation to certain activities, as follows: Associate director of finance and the health and safety manager Head of programmes Clinical risk manager Health and safety related incidents, complaints and claims IT and information governance related incidents, complaints and claims Incident reporting system, incidents relating to clinical practice, complaints BACHS 2010 page 4 of 21

5 Complaints manager Claims manager Table 1 Specific responsibilities Complaints Claims 5.3 Associate directors, heads of service and other managers are responsible for ensuring this policy is accessible to staff and implemented across the services and functions for which they are responsible. This involves supporting individuals in dealing with incidents, complaints and claims and signposting them to other sources of advice and support as necessary. 5.4 Individual members of staff are responsible for ensuring they work in accordance with this policy and for bringing to the attention of their manager any issues that prevent this. 6. Managing an incident 6.1 If there is any indication that an incident may qualify as a serious untoward incident (SUI) it must be dealt with in accordance with the current SUI policy and procedures and the clinical risk manager informed as soon as possible. 6.2 Incidents which do not meet the criteria for classification as a SUI should be managed as follows. 6.3 The circumstances of each incident are different and judgement must be exercised as to precisely how the incident is managed, who undertakes what duties and what constitutes a proportionate response. Staff should only act within their capabilities and should take care not to jeopardise their own or others safety. 6.4 Service managers must be notified a soon as possible after an incident has taken place. Where an incident has resulted in moderate or severe harm or death this notification should take place immediately and the relevant head of service informed too. (Out of hours the senior manager on call should be notified). 6.5 The priority immediately following an incident is to ensure the immediate safety and care of all people involved. 6.6 Where there are key environment factors the scene should be preserved until sufficient information has been obtained to support the investigation. Similarly any equipment thought to be of significance should be isolated and preserved. 6.7 A contemporaneous record of events must be made. This should include a log of telephone calls and conversations, actions, decisions and their rationale. Records need to be specific about the date and timing of events and who did what. In due course these must be incorporated within or attached to the Prism incident report. 6.8 Consideration should be given as to whether witness statements will be required. Ideally these should be obtained as reasonably possible after the incident, whilst people s memories are fresh. 6.9 Communication with and support for involved patients and/or their carers should commence as soon as possible in accordance with the current being open policy. BACHS 2010 page 5 of 21

6 6.10 If there is media interest in the incident the communications team must be informed without delay. Under these circumstances it is essential that all reasonable steps are taken to inform patients, staff and relevant others before releasing information to the media Senior staff and service managers must ensure that appropriate communication takes place with staff involved and affected by an incident, directing them to additional sources of support where necessary, such as clinical supervision, the Occupational Health Service, which offer a staff counselling service and the staff member s own professional organisation or trade union The management of staff directly involved in a patient safety incident must be informed by the National Patient Safety Agency s Incident Decision Tree (NPSA 2005), which takes account of organisational as well as individual factors and promotes a consistent and fair approach. 7. Reporting an incident 7.1 Whenever an incident occurs it must be reported online using the Prism incident reporting system as well as directly to the service manager by telephone or in person. Near misses and hazards should be reported in the same way. 7.2 Incident reports must be made as soon as possible after the event and at the latest within 24 hours of the incident being recognised. 7.3 In exceptional circumstances where staff are unable to access the online reporting system a paper form may be completed and submitted simultaneously to both the relevant service manager and the risk support manager (appendix 1). 7.4 Incident reporters are required to provide sufficient information to enable a preliminary assessment of the severity of the incident and to enable investigation to take place. Guidance of the grading of incidents is currently being developed and will be incorporated into this policy in due course. 7.5 Often it is essential for effective investigation that details of the persons involved and affected are reported. It should be noted that where patient and staff details are entered into the appropriate pages of the Prism form these are held in the strictest confidence. (Identifying details should never be entered into the incident description and immediate action fields) 7.6 The risk support manager is responsible for ensuring that patient safety incident related information is uploaded to the NPSA s incident reporting and learning system in accordance with the NPSA s requirements. 7.7 Service managers are responsible for ensuring that certain types of incidents are reported to other external agencies where necessary. These requirements are detailed in appendix It is the service manager s responsibility to ensure that more senior managers are made aware of incidents as necessary, in particular where there are external reporting requirements and/or media interest. BACHS 2010 page 6 of 21

7 8. Investigating incidents, complaints and claims 8.1 The level of investigation afforded to an incident, complaint or claim is determined according to the degree of harm resulting from the incident. 8.2 Incidents, complaints and claims are subject to a minimum level of investigation in accordance with the following table and descriptions (informed by the NPSA s RCA report writing tools and templates 2008). It must be noted that the circumstances of each incident, complaint or claim differ and occasionally it may be appropriate to escalate the level of investigation beyond that suggested in this table. Incident, complaint or claim characteristics Resulted in death or severe harm 1 No, low or moderate harm 1, but could have realistically resulted in severe harm or death Where relevant national guidance has been issued, eg NPSA alerts Resulted in moderate harm 1 Frequently occurring with no or low harm 1 No, low or moderate harm 1, but may represent significant concern or systemic service failure No, low or moderate harm 1, but attracting public concern or media interest Frequently occurring with moderate harm 1 Minimum level of investigation Comprehensive (level2) Concise (level 1) Aggregate Other incidents graded green or yellow Proportional local investigation 8.3 A comprehensive investigation: is overseen by the chief operating officer or an associate director is conducted in accordance with formal terms of reference is conducted by staff not involved in the incident or service in which it occurred is undertaken by person(s) experienced and/or trained in human factors and root cause analysis techniques may be conducted by a multidisciplinary team, or involve experts/expert opinion/independent advice or specialist investigator(s). includes the use of appropriate root cause analysis tools is conducted to a proportionate level of detail involves patients, relatives and carers as appropriate, with support from advocacy services as necessary 1 Work is underway to more precisely define severe, moderate and low harm in the context of BACHS services. In the interim reference should be made to the NHSBA risk management strategy and the NPSA risk matrix at pages 6-7 BACHS 2010 page 7 of 21

8 leads to robust recommendations for implementing and sharing learning, locally and nationally as appropriate concludes with a formal written report and action plan signed off by the chief operating officer or associate director 8.4 A concise investigation is overseen by the relevant head of service may be conducted by staff local to the incident should involve person(s) experienced and/or trained in human factors and root cause analysis techniques includes the use of appropriate root cause analysis tools is conducted to a proportionate level of detail involves patients, relatives and carers as appropriate, with support from advocacy services as necessary concludes with the completion of an investigation template, the creation of an action plan and plans for shared learning 8.5 An aggregate investigation comprises an investigation into a series of incidents or the amalgamation of findings from previously conducted investigations. The requirement for an aggregate investigation will most likely be initiated by a committee in response to routine or exceptional incident, complaints or claims reports. In these cases the investigation will normally be undertaken by a service manager include the use of appropriate root cause analysis tools be conducted to a proportionate level of detail should involve person(s) experienced in data management and statistical analysis involve patients, relatives and carers as appropriate, with support from advocacy services as necessary conclude with a formal written report and recommendations for implementing and sharing learning, locally and nationally as appropriate. 8.6 The precise definition of a proportionate local investigation is to be determined by the service manager according to the circumstances of the incident. A record of the findings and implementation of learning locally should be made on Prism and shared at business unit risk and governance meetings. Who should investigate? 8.7 The investigator for each incident is determined in accordance with table 1 above. Effective investigation relies on the expertise of the investigator/s and sufficient resource being made available (including release of the investigator from regular duties where necessary) for the work being undertaken in a timely manner and these factors must be taken into account. 8.8 Where investigations are expected to require a range of expertise it is appropriate to consider appointing an investigation team. Sometimes it is more appropriate to co-opt individuals at the point their expertise is required. BACHS 2010 page 8 of 21

9 8.9 Investigators undertaking comprehensive, concise and aggregate investigations should normally have undertaken training in root cause analysis (RCA) techniques. They are referred to the suite of RCA tools on the NPSA website and recommended to seek advice and support from the risk managers as necessary. The investigation process 8.10 BACHS recognises the vast majority of NHS staff are committed to delivering the best possible service but that nevertheless all humans make mistakes. Without exception investigations will accept human fallibility and consider the organisational factors which allowed harm to occur. Blame will be reserved for clear cases of negligence, recklessness or criminality and the focus of the investigation will be to identify lessons to be learned It is expected that all incident, complaint and claim investigators will use investigation and root cause analysis techniques relevant to the situation. The NPSA provides a useful resource at (NPSA 2008) and the Health and Safety Executive a resource at (HSE 2004) 8.12 In particular, BACHS is concerned that staff involved in incidents, who will naturally be upset to be involved are not further distressed by clumsy investigation techniques. Care must be taken about how the necessity for investigation is communicated to staff and interviews must be conducted skilfully using cognitive interviewing techniques (NPSA 2008, Milne et al 1999). The NPSA s incident decision tree (NPSA 2005) is particularly useful in informing lines of enquiry to be pursued at interview to determine organisational as well as individual factors The root cause analysis method of investigation involves: information gathering information mapping identifying problems and highlighting good practice identifying contributory factors (including equality and diversity issues where these are relevant) agreeing the root causes generating solutions recommending and reporting It is important that investigations take into account issues specific to equality target groups: age, disability, gender, race, religion or belief and sexual orientation. Concurrent internal and external investigations 8.15 Internal inquiries must not interfere with other investigations. Reference should be made to the Memorandum of Understanding between the DH, HSE and Association of Chief Police Officers (February 2006) on investigating incidents with which the police or Health and Safety Executive are involved. BACHS 2010 page 9 of 21

10 Access to confidential records 8.16 Where it is necessary for an internal investigator or external investigator commissioned by BACHS to refer to or review confidential records, full access will be granted to all records held by BACHS, unless the patient concerned has explicitly withheld permission. External investigators are required to sign a confidentiality statement. Should records need to be requested from another organisation this must be done in accordance with that organisation s information governance requirements. Professional issues and criminal acts 8.17 If in the course of an investigation procedural matters relating to professional standards, conduct and performance are identified, the investigating team must refer these matters to the relevant head of service who will make a decision about whether to pursue the issues through alternative tpct policies, such as Performance Improvement Policy or the Disciplinary Policy and Procedure If there are concerns that a criminal act has taken place then the scene of the incident must be secured and preserved, all investigations will cease and the relevant head of service and and the police notified immediately. Safeguarding children and vulnerable adults 8.19 If at any time during the investigation safeguarding concerns arise, these must be managed in accordance with current safeguarding adults and safeguarding children policies. Timescales for investigations 8.20 Prompt investigations help to ensure that key information is gathered before memories begin to fade. It is expected that, for the vast majority of incidents, investigations will be completed and reports signed off within 6 weeks of the incident being reported (or the need being identified for an aggregate investigation). The time scale for investigations into complaints and claims will be determined according to the nature of the complaint or claim and in accordance with the relevant policy. Record keeping 8.21 It is the lead investigators responsibility to maintain accurate records of the investigation, to ensure that they are stored securely and ultimately attached to the Prism incident report. 9. Learning from incidents, complaints and claims 9.1 A key purpose of investigating incidents, complaints and claims is to ensure that lessons are learned and implemented to reduce the risk of recurrence. This is achieved by sharing the lessons learned from individual incidents, complaints and claims and by aggregating and analysing data to identify themes, trends and priorities for improvement. Learning from individual incidents, complaints and claims 9.2 At the conclusion of any investigation an action plan must be drawn up which addresses outstanding issues of concern and ensures that lessons learned are implemented and BACHS 2010 page 10 of 21

11 shared. Each action plan must make clear who should do what, by when, and who has responsibility for monitoring its implementation and for ensuring that appropriate action is taken when issues arise with implementation. A template action plan is attached as appendix Responsibility for the monitoring of action plans will be determined in accordance with the incident, complaint or claim characteristics and the level of investigation, as suggested in the following table. level of investigation comprehensive person responsible for monitoring implementation chief operating officer or associate director overseen by committee/group relevant sub-committee of the board concise head of service business unit governance meeting proportional local investigation service manager team meeting service group meeting business unit governance meeting 9.4 It is expected that the learning from incidents, complaints and claims is routinely discussed by all the above groups and opportunities identified for further local implementation of learning and for sharing learning more widely. 9.5 The learning from incidents complaints and claims may be shared and implemented in a number of ways, for example through incorporation into procedural documents, training events, via team brief and the staff newsletter, discussion at internal and external network meetings. Whilst a culture of openness is strongly encouraged, care must be taken not to divulge confidential information and the sensitivities of individuals and teams involved in the incident, complaint or claim must be taken onto account. Learning from the aggregation and analysis of incident, complaints and claims data 9.6 In addition to extracting learning from the investigation of individual incidents, complaints and claims much can be learned from the aggregation and analysis of data. Over time themes and trends can be identified and aggregate investigations undertaken as necessary to inform improvement planning. 9.7 As incidents are reported they are categorised and data can be extracted from the Prism incident reporting and management system by category. Aggregate data is supplied routinely and on request by the risk support manager. 9.8 Incident, complaints and claims data is aggregated and reviewed on a quarterly basis. As a minimum, reports should make clear the number and severity of incidents. Further to this the type and extent of analysis undertaken must be proportionate to the impact of the incident or complaint on patients, staff and services and appropriate statistical and presentation techniques used. In particular the use of statistical process control techniques will ensure that common cause variation and special cause variation are taken into account and inform decision making. 9.9 Responsibility for the analysis of this aggregate data lies with the following officers and committees. It is for each committee to determine how this information should inform improvement planning, to develop and oversee the implementation of action plans, where appropriate and to monitor the impact of these actions. BACHS 2010 page 11 of 21

12 Category of Responsibility for the analysis of aggregate data incident Officer Group or committee Patient safety incidents clinical risk manager clinical risk and governance committee Medical devices clinical governance manager clinical risk and governance committee (via the medical devices group) Health, safety health and safety manager Finance estates and heath and security Information technology and information governance complaints claims head of programmes clinical risk manager, in conjunction with the complaints manager head of programmes, in conjunction with the claims manager and safety committee Information governance and records management committee, and/or the Information and systems development sub-committee clinical risk and governance committee clinical risk and governance committee 9.10 Membership of the above committees is designed to ensure that appropriate links are made to ensure effective management of issues arising. Key issues arising may ultimately be escalated to the board by the relevant associate director. 10. Training and competency requirements 10.1 All staff are made aware of the importance of incident reporting at induction and at ongoing mandatory training and all are directed to the online learning package about incident reporting Further training is delivered to managers as part of the mandatory risk management for managers training and selected individuals will be identified by their head of service to undertake more in depth training in investigative techniques Officers with responsibility for analysing aggregate data require a basic knowledge of statistical process control techniques. 11. Monitoring 11.1 The clinical risk manager, with the support of the complaints manager and the claims manager will monitor implementation of this policy by undertaking a bi-annual audit, taking into account NHSLA monitoring requirements. The first of these audits will commence no sooner than six months and no more than 18 months following approval of this policy Findings of the audit will be reported to the clinical risk and governance sub-committee. BACHS 2010 page 12 of 21

13 12. References Department of Health (2004) Standards for Better Health [online] [accessed ] Available from e/dh_ Health and Safety Executive (2004. Investigating accidents and incidents: A workbook for employers, unions, safety representatives and safety professionals [online] [accessed ] Available from Milne R, Bull R (1999) Investigative Interviewing: Psychology and Practice Chichester: Wiley NHS Litigation Authority (2009) NHSLA Risk Management Standards for Acute Trusts, Primary Care Trusts and Independent Sector Providers of NHS Care [online] [accessed ] Available from National Patient Safety Agency (2005) Incident Decision Tree [online] [accessed ] Available from National Patient Safety Agency (2008) Root Cause Analysis (RCA) report-writing tools and templates [online] [accessed ] Available from Woloshynowych M, Rogers S, Taylor Adams and Vincent C (2005) The investigation and analysis of critical incidents and adverse events in healthcare Health Technol Assess 2005;9(19) BACHS 2010 page 13 of 21

14 INCIDENT REPORTING FORM APPENDIX 1 Only to be used in exceptional circumstances when access to online reporting is impossible DATE OF INCIDENT TIME OF INCIDENT LOCATION OF INCIDENT NAME OF PERSON INVOLVED STAFF MEMBER? SERVICE USER? OTHER - PLEASE STATE NHS NUMBER: DATE OF BIRTH: WHAT HAPPENED? WHAT WAS THE OUTCOME? IMMEDIATE ACTION TAKEN ANY LONGER TERM ACTION PLANNED NAME OF PERSON COMPLETING FORM: JOB TITLE: BASE: CONTACT NUMBER: NAME OF LINE MANAGER: USING THE FOLLOWING GRID FOR REFERENCE, PLEASE INDICATE A) THE SEVERITY OF HARM RESULTING FROM THIS INCIDENT: B) THE LIKELIHOOD OF RECURENCE OF SUCH AN INCIDENT: C O N S E Q U E N C E E GRADING MATRIX Rare (1) Unlikely (2) Possible (3) Likely (4) Almost Certain (5) Catastrophic (5) Major (4) Moderate (3) Minor (2) Insignificant (1) Please send this form without delay to your line manager and a copy to the BACHS risk support manager at Douglas Mill BACHS 2010 page 14 of 21

15 EXTERNAL REPORTING REQUIREMENTS APPENDIX 2 REPORT TO: CIRCUMSTANCES: REPORT BY: TIMESCALES: Coroner General Practitioner Sudden or unexpected death of a patient Suicide to be determined by head of service immediately, or as soon as practicable Major injury to a patient Police Death or injury where the person in charge considers there to be unusual or suspicious circumstances to be determined by head of service immediately, or as soon as practicable Theft of Trust property Malicious damage to Trust property Violent or aggressive incidents where the person in charge considers a police presence is necessary Arson Medicines and Healthcare products Regulatory Agency (MHRA) Any incident involving a medical device that has led, or could lead were it to happen again to: death, life threatening injury or illness deterioration in health the necessity for medical or surgical intervention unreliable test results leading to inappropriate diagnosis or therapy Incidents involving adverse drug reactions to medicinal products to be determined by head of service as soon as practicable Health and Safety Executive and NHS Estates When a defect or fault related to buildings engineering plant, installed services or non medical equipment results in any of the following: any fatal accident or serious injury any explosion or sudden fracture of any pressure vessel, pressurised system or steam/ high pressure hot water main any major electrical explosion any runaway and crash of a passenger lift to be determined by head of service in conjunction with the risk manager (health & safety) refer to health & safety policy Health & Safety Executive (HSE) For any accidents to a patient, employee, visitor, contractor, volunteer or trespasser involving the work environment or work activities Which results in any of the following: death to be determined by head of service in conjunction with the risk manager (health & safety) refer to health & safety policy fracture other than the fingers, thumbs or toes any amputation dislocation of the shoulder loss of sight (temporary or permanent) chemical or hot metal burn to the eye any injury from electric shock or electric burn leading to unconsciousness or requiring resuscitation or if their stay in hospital is extended more than 24 hrs due to their injuries any injury leading to hypothermia, heat induced illness or to unconsciousness any injury requiring resuscitation any injury extending their hospital stay for more than 24 hrs any injury that results in their admission to BACHS 2010 page 15 of 21

16 REPORT TO: CIRCUMSTANCES: REPORT BY: TIMESCALES: hospital for more than 24 hrs loss of consciousness caused by asphyxia loss of consciousness caused by exposure to harmful substance loss of consciousness caused by a biological agent the absorption of any substance by inhalation, ingestion or through the skin which results in acute illness requiring medical treatment the absorption of any substance by inhalation, ingestion or through the skin which results in loss of consciousness acute illness which requires medical treatment where there is reason to believe that this resulted from exposure to a biological agent, its toxins or infected material Any employee (permanent or temporary) being absent or unable to perform their duties fully for more than three days as a result of an accident at work. This includes any annual leave or off duty days. Environmental Health Department Any incident of food poisoning originating in or having been transferred into, the tpct. to be determined by head of service NHS Bradford and Airedale Serious untoward incidents (SUIs) clinical risk manager within 24 hours of the incident occurring Local Security Management Service All incidences of physical assault are to be reported on a PARS form (Physical Assault Reporting System) via the Health and Safety Manager, to the Local Security Management Service. This information will feed into the overall prevention of crime strategy. health & safety manager as soon as practicable BACHS 2010 page 16 of 21

17 BRADFORD AND AIREDALE COMMUNITY HEALTH SERVICES APPENDIX 3 PRISM ref XXXX INCIDENT ACTION PLAN ACTION PLAN LEAD: NO ISSUE ARISING FROM INVESTIGATION ACTION LEAD OFFICER TARGET DATE DATE COMPLETED OUTCOME/ EVIDENCE BACHS 2010 page 17 of 21

18 EQUALITY IMPACT ASSESSMENT APPENDIX 4 Stage One: Screening of a policy, procedure, tender or strategy 1. Name of policy, procedure, tender or strategy. Is it a policy, strategy, procedure or practice? Policy on the reporting and management of incidents and the investigation of and learning from incidents, complaints and claims Policy 2. Who has been consulted? associate director of quality and operations members of the clinical risk and governance committee health and safety manager claims manager complaints manager risk support manager equality and diversity team 3. Main aims To ensure that all incidents are effectively managed and reported learning is derived from incidents, complaints and claims and used to inform priorities for service improvements 4. How has the policy been explained to those most likely to be affected? Direct responses made to questions raised at consultation. BACHS 2010 page 18 of 21

19 Collecting and collating existing information and data General Age Disability Equality target group 1. Is the policy likely to have a potential differential impact with regards to the equality target group listed? 0 = no 1 = little 2 = medium 3 = high 2. How have you arrived at the conclusions in box 1? i. Who have you consulted? (appropriate individuals/groups internally and externally) ii. What have they said? iii. What information/data have you interrogated? (library search, complaints data, PALS, research reports, local studies, advice from internal and external specialists) iv. Where are the gaps in your analysis? v. How will your paper promote the equality duties if they apply? This policy promotes the equitable treatment of people by ensuring that all incidents, complaints and claims are appropriately investigated and that relevant information is aggregated and analysed and that those issues which cause most concern are addressed as priorities. At present it is not possible to disaggregate this data by equality strand but we have agreed to include at least one scenario about learning from incidents and equality issue(s) in our mandatory equality & diversity training. Older people Young people Children Early years Sensory disabilities Physical disabilities Learning disabilities Mental health 0 0 as above BACHS 2010 page 19 of 21

20 Gender Race Religion or belief Sexual orientation Summary Men Women Transgender Minority ethnic communities Gypsies and travellers Christian Muslim Hindu Buddhist Sikh Jew Other Lesbian Gay men Bisexual 0 as above 0 as above 0 as above 0 as above Is a more full equality impact assessment required? No Please describe the main points arising from the initial screening here that support your decision This is a broad policy. It requires the authors of other procedural documents to undertake equality impact assessments in accordance with current equality and inclusion requirements but does not impact directly upon equality target groups. We have agreed to include at least one scenario about learning from incidents and equality issue(s) in our mandatory equality & diversity training. Policy lead conducting impact assessment: Helen Torevell, Clinical Risk Manager Approved by (member of the equality and diversity team): Lynne Carter, Head of Equality & Diversity Date: BACHS 2010 page 20 of 21

21 APPENDIX 5 SUMMARY OF POLICY DEVELOPMENT AND CONSULTATION This policy was developed in preparation for the NHSLA assessment due to take place in March It was informed by the former BAtPCT Policy for the reporting and management of incidents, December 2008 and BAtPCT Policy and procedure for the investigation of incidents, complaints and claims, December The changes made to construct this document largely relate to the application of existing principles within the context of BACHS accountability framework. The sections on the analysis of aggregate data and learning from incidents, complaints and claims are new requirements but largely reflect existing practice. Consultation on this document was limited prior to approval because of deadlines for preparation for the NHSLA assessment but will continue to ensure that all have the opportunity to comment. To date, those invited to comment are: associate director of quality and operations members of the clinical risk and governance committee health and safety manager claims manager complaints manager risk support manager. Policy on the reporting and management of incidents and the investigation and implementation of learning from incidents, BACHS 2010 page 21 of 21