NHS Business Services Authority Information Security Incident Reporting Procedure

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1 NHS Business Services Authority Information Security Incident Reporting Procedure NHS Business Services Authority Corporate Secretariat NHSBSAIS002

2 Issue Sheet Document reference NHSBSAIS002 Document location F:\CEO\IGM\IS\BSA Title NHS Business Services Information Security Incident Reporting Procedure Author Gordon Wanless Issued to All NHSBSA staff Why issued For action Last Reviewed 27 January 2011 Revision Details Version Date Amended by Approved by Details of amendments Initial Release IGSG - a G Wanless IGSG Large scale changes due to document Capita involvement

3 Contents Page 1. Introduction and Scope 1 2. Incident Identification 1 Appendix A Incident Reporting Form (NHS Pensions use only) 1 Meeting\NHSBSAIS002a - NHSBSA Information Security Incident Reporting Procedure.DOC Page 3 of 8

4 1 Introduction and Scope This procedure provides guidance on the reporting of security incidents, breaches or suspected incidents and breaches. The scope of this document is limited to those security incidents that affect NHSBSA only. This policy requires that details of all incidents resulting in breaches of security (or near misses), whether by staff or others and whether deliberate or accidental, must be reported as soon as possible. Incidents which must be reported include those which: Pose a threat to personal safety Pose a threat to Restricted or other sensitive data May cause embarrassment to NHSBSA Pose a threat to privacy Result in financial loss Result in the disruption of NHSBSA activities. Examples of such incidents include (but are not limited to): Unauthorised modification/removal of system software, hardware or connections Unauthorised modification or deletion of system data Disclosure of system data to unauthorised personnel Hacking or attempted hacking by staff, third-parties or outsiders Suspected breach of software copyright Suspected breach of the firewalls or malicious attack Unattended terminals repeatedly left logged in. Repeated lock out of users accounts due to repeated failure to enter correct password. Attempts to obtain information by deception (e.g. bogus phone calls, social engineering or s) Disclosure of Restricted or confidential information (especially passwords or other access control data) to unauthorised personnel Discovery of malicious or unauthorised software, such as a computer virus or computer game Suspected or actual illegal activity (e.g., breaches of the Computer Misuse Act, Data Protection Act, Designs Copyright and Patents Act, or use for storing illegal images or text) Receipt of malicious/threatening phone call i.e. bomb threat. Receipt of threatening or repeated receipt of offensive Missing or amended accounting records Loss of portable computing equipment e.g. Laptop; Blackberry etc Actual or attempted unauthorised entry to a secure area

5 Unauthorised, unescorted visitors Actual or attempted theft of property. Deliberate damage to property. Activation of intruder/fire alarms Fraud (by staff, a third party or a member of the public) Where a suspected security breach has been caused (through wilful intent or culpable negligence) disciplinary action may be sought in line with the appropriate misconduct guidelines. This security incident reporting process is formed from three key phases: Identification (of a security incident/breach.) Containment Resolution An explanation of each phase will be given below, along with guidance to help staff handle incidents in a controlled, methodical manner. 2 Incident Identification Where a breach, or suspected breach, or a near miss of personnel, physical, logical, hardware, software or documentary security is identified by a member of staff, it should be reported as soon as possible to the correct people, in the correct manner. The reporting of incidents is for the common good and the major concern is not to apportion blame, but to contain, then resolve the situation and prevent a future reoccurrence. Failure to report incidents is a serious matter as it could leave the business exposed to repeated and more serious attacks/breaches. The correct identification of a security incident must encompass the detection, confirmation and communication of the relevant facts. 2.1 Detection For obvious types of breach, e.g. identifying intruders or suspect packages, it is reasonable to expect all staff to be capable of detection. To detect certain types of incident, specialist knowledge may be required. Unauthorised System Access for example, will normally be identifiable only by staff with system administrator knowledge, skills, access and experience. 2.2 Confirmation Some staff will have the ability to both detect and confirm the existence of a valid security breach due to their specialist/technical knowledge or training. Generally, most staff will identify a potential security breach which will then be subsequently confirmed or proved false by someone with the requisite knowledge or training. The following should be established as rapidly as possible: Meeting\NHSBSAIS002a - NHSBSA Information Security Incident Reporting Procedure.DOC Page 5 of 8

6 When the incident occurred; When the incident was discovered; Details of the person reporting the incident; Whether a near miss or an actual incident; What data and data media is involved; Who is involved (e.g. individuals, organisations, patients); Where the incident occurred (or If live, where occurring); The sensitivity of the data and if personal data, the number of persons involved; Whether the information and/or media was protectively marked and if so at what level; Who is aware of the incident; Whether and how the data might be used by a third party; The Information Asset Owner for the information involved; The immediate cause of the information loss e.g. breach, theft, misplaced, destroyed; The location of the information at the point of loss e.g. in the post, with a courier, in a NHSBSA office: o If in the post How was it sent? Was it double enveloped? Was the address verified? Where was it sent from? Was it double enveloped? o If with a courier From where was it collected? Was it sent with track and trace? Was it collected by the expected courier? Was the address verified? Was it double enveloped? o If from a NHSBSA office From where was it accessed / stolen? (e.g. terminal, public area, desk, drawer, filing cabinet, office) Was it protectively marked? If it was protectively marked, was it stored appropriately? The crime number if the incident has been reported to the Police. 2.3 Communication The correct notification process following a security breach involves a set line of communication. On discovering a breach or a suspected breach, the member of staff should in the first instance contact their local Incident Management Team, where available (this team is likely to comprise of the following individuals: Line Manager, Security Guards, Security Manager and Operations Manager). Once local management have visibility of the incident, the incident should be logged, with all the information identified in 2.2 above, as follows: Meeting\NHSBSAIS002a - NHSBSA Information Security Incident Reporting Procedure.DOC Page 6 of 8

7 For NHS Pensions only, an incident reporting form must be completed (See Appendix A). Once completed a copy should be sent to the HoIG and a copy kept by the line manager. If the incident is a significant one (e.g. compromise of personal data), the HoIG will inform the Caldicott Guardian. For business areas apart from NHS Pensions, the incident should be logged into AMDOCS by contacting the Capita Service Desk as soon as practicable. When raising the call with the Capita Service Desk it must be made clear that the call relates to a potential security incident/breach, this will ensure that it is prioritised correctly. Depending on which business area the security incident relates to, the Capita Service Desk will use the following escalation list: CFSMS Incidents: Name Telephone Tony Burgess Mobile: Gordon Wanless DD: Mobile: Tony Church DD: Mobile: Mike Grieveson DD: Mobile: Rosie Mullen DD: Mobile: NHSBSA Incidents (i.e. all other parts of the NHSBSA apart from CFSMS and NHS Pensions): Name Telephone Tony Burgess Mobile: Gordon Wanless DD: Mobile: If the incident is a significant one (e.g. compromise of personal data), the HoIG (i.e. Gordon Wanless), should be made aware of it immediately (i.e. within 2 hours of the incident being reported), who will in turn inform the Caldicott Guardian. Once the call has been logged on AMDOCS, the Capita Service Desk shall then make contact with the relevant line of service and/or local IT support. Please be aware any security incident involving personnel information i.e. name, contact details will be seen by all staff members who have access to AMDOCS. It is advised if a security incident involves personnel information the incident should be communicated another form i.e. or telephone call. Meeting\NHSBSAIS002a - NHSBSA Information Security Incident Reporting Procedure.DOC Page 7 of 8

8 Appendix A Incident Reporting Form (NHS Pensions use only) Date of Incident: Place of Incident: Name (of person who discovered incident): Brief Description of Incident: Brief Description of Any Action Taken (at time of discovery): Date Form Sent to HOIG: Signature: For HoIG Use Only Incident Number: Date Form Received: Date CG Informed: Brief Description of Action Taken by ISM / HoIG / CG: Date of Follow-up & Brief Description of Follow-up Action: Meeting\NHSBSAIS002a - NHSBSA Information Security Incident Reporting Procedure.DOC Page 8 of 8

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