INCIDENT MANAGEMENT POLICY

INCIDENT MANAGEMENT POLICY Last Review Date January 2015 Approving Body Quality and Safety Committee Date of Approval March 2015 New Review Date March 2018 Review Responsibility Chief Nurse Chief of Corporate Affairs Version 2.0 1

REVISIONS/AMENDMENTS SINCE LAST VERSION (IF APPLICABLE) Date of Review January 2015 Amendment Details The original PCT document has been revised to reflect the Clinical Commissioning group establishment Reflect the Clinical Commissioning Group Structure 2

CONTENTS PAGE DEFINITIONS 4 SECTION A DEFINITITIONS 6 Definition of an Incident and Serious Incident 6 SECTION B POLICY 8 1. Policy Statement, Aims & Objectives 8 2. Legislation and Guidance 10 3. Scope 11 4. Accountabilities and Responsibilities 11 5. Dissemination, Training and Review 14 SECTION C PROCEDURE 16 1. Procedure in the event of an Incident (including serious incidents) 16 2. Procedure in relation to Serious Incident 16 3. Trends and Lessons Learnt 17 4. Serious Incidents involving a Doncaster CCG Commissioned Service 18 SECTION D NHS DONCASTER CCG SERIOUS INCIDENT PERFORMANCE MANAGEMENT PROCEDURES 1. Performance monitoring the management of Serious Incidents (except child safeguarding incidents) 2. Performance monitoring the management of child safeguarding Serious Incidents 3. Monitoring Serious Incident Trends, Themes and Patterns 20 4. Obtaining Assurance of Action Plan Completion 21 5. Reporting on Never Events 21 19 19 20 APPENDICES 22 A Useful Contacts 22 B Reportable External Bodies 23 C Serious Incident Performance Monitoring Flowchart 26 D NHS Doncaster CCG Incident Reporting Form 27 3

DEFINITIONS Abuse Term Consequence Harm Information Governance Serious Incident Investigation NHS Doncaster Clinical Commissioning Group NHS Funded services and care Definition Abuse is a violation of an individual s human rights by any other person or persons. A result or effect of some previous occurrence Physical or mental injury, moral evil or wrongdoing, to injury physically, morally or mentally Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious. The act or process of investigating, careful search or examination in order to discover the truth NHS Doncaster Clinical Commissioning Group is the Commissioning Organisation for Health in Doncaster. The treatment of patients in: NHS establishments or services; in independent establishments including private healthcare; or the patient s home or workplace. Either all or part of the patient s care in these settings is funded by the NHS. Permanent harm RIDDOR Never Event Approval Policy Directly related to the incident and not related to the natural cause of the patient s illness or underlying condition, permanent lessening of bodily functions, sensory, motor, physiologic or intellectual, including removal of the wrong limb or organ, or brain damage. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995. Serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Incidents that fall within this category are defined nationally. The act of approving, of formal agreement. A deliberate plan of action adopted or pursued by an individual organisation to guide decisions and achieve rational outcomes. A policy is a statement of intent, describing the approach or course of action the organisation is taking in respect of a particular issue. Policies are underpinned by relevant evidence based procedures and guidelines and enable management and staff to make correct decisions, work effectively and comply with relevant legislation and organisational aims and objectives. 4

Term Procedure Procedural document Strategy Definition A set of step-by-step instructions that describe the appropriate method for carrying out tasks or activities to achieve the highest standard possible and to ensure efficiency, consistency and safety. An overarching term for the full range of strategies, policies and procedures. A long term plan designed to achieve particular goals or objectives. A strategy is often a broad statement of an approach to accomplishing these desired goals or objectives and can be supported by policies and procedures. 5

SECTION A DEFINITIONS DEFINITION OF AN INCIDENT AND SERIOUS INCIDENT For the purpose of this policy an incident is any incident/accident, near miss or untoward event, which had, or may have had the potential to cause harm, dissatisfaction or injury to persons, loss or damage to property i.e. result in an adverse outcome. This definition includes hazards, accidents, ill health, dangerous occurrences and near misses. A serious incident requiring investigation is defined as an incident that occurred in relation to NHS funded services and care resulting in one of the following; Unexpected or avoidable death of one or more patients, staff, visitors or members of the public Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-threatening intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (the includes incidents graded under the NPSA definition of severe harm) A scenario that prevents or threatens to prevent a provider organisation s ability to continue to deliver health care services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure Allegations of abuse Adverse media coverage or public concern about the organisation or the wider NHS A Never Event all never events are defined as serious incidents although not all never events necessarily result in severe harm or death. Never Events are defined nationally and updated annually Adult Safeguarding Serious Incident: Where the incident involves a vulnerable adult, consideration should be given to raising the alert as an adult safeguarding concern, refer to Safeguarding Adults Policy for procedure. Examples of Serious Incidents Examples of serious incidents include (but are not limited to); Safeguarding incidents meeting the definition. Death or serious injury to a member of staff including all commissioned services staff (in the course of their NHS duties) Serious fires or other serious damage, which occurs on NHS premises. Of particular concern would be any fire which resulted in casualties or major disruption to services Serious or unexplained outbreaks of infection or disease in hospital or the wider community including care homes (e.g. food poisoning, Legionnaire s Disease) or the confirmed transmission of serious infectious disease between an NHS staff member and a patient (e.g. HIV/Hepatitis B) Major system failure e.g. patient referral system failure for further review/consultation/treatment Major service disruption e.g. due to power failure, flooding, etc Major breach of patient confidentiality e.g. theft of patient notes or computers/laptops containing patient information; discovery of patient records in public area see Information Governance Guidance available on Doncaster CCG website. 6

Incidents/concerns (including those identified through whistleblowing) regarding the actions of NHS staff (including care home staff) Examples include fraudulent behaviour, gross misconduct and actions resulting in harm to patients. This could lead to suspension/summary dismissal, media interest and the involvement of the criminal justice system. A pattern emerging that is causing concern such as a high number of complaints regarding a member of staff a particular service and/or hospital/care home that may warrant further investigation and action. The development of a pressure ulcer Grade 3 and 4 Children 17 or under being admitted to a mental health in patient bed Near Misses An example could constitute a system failure, the result of which is incorrect/delayed diagnosis. This may not have any serious consequences for some patients, but for others could lead to the wrong treatment/serious delay in treatment and ultimately to death. Information Governance Serious Incidents Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals irrespective of media involvement should be considered as serious. An information governance incident that leads to damage of service, organisation or NHS reputation Refer to Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents requiring Investigation (IG SIRI) available from the,health and Social Care Information Centre Safeguarding Children Serious Incidents Any case where there is initial indications that a child has sustained a potentially life threatening injury which may be through abuse or neglect or serious sexual abuse, or sustained serious and permanent impairment of health or development through abuse or neglect. A case where a child dies (including death by suicide) and abuse or neglect is known or suspected to be a factor in the child s death and there will be a Serious Case Review (Working Together 2013) This list is NOT exhaustive nor in any order of importance. Personal judgement will need to be exercised when deciding whether or not to report and manage an incident as a Serious Untoward Incident. If in doubt report or contact the Chief Nurse, Head of Quality in Contracts and Designated Nurse for Safeguarding Adults, or NHS England, Local Area Team for advice. 7

SECTION B - POLICY 1. Policy Statement, Aims & Objectives 1.1 This Policy represents the agreed Policy and Procedure of NHS Doncaster CCG in relation to the reporting and management of Incidents. It also represents the agreed policy and procedure in relation to the CCGs responsibility to Performance manage the Serious Incidents that occur within the services it commissions. 1.2 The aim of this policy is to ensure that the organisation captures all incidents (including serious incidents and never events), learns and shares lessons from them to reduce the chance of similar incident happening again and takes appropriate action to protect patients, staff, contractors, volunteers and members of the public from harm. The policy also relates to the Performance management of Serious Incidents within Commissioned Services. By following the procedures outlined the organisation will:- Document the organisation s commitment to a fair blame culture to encourage reporting of all incidents (including serious incidents and Never Events ) to enable the organisation to learn and share lessons learnt across the wider health community. Ensure all incidents are captured through early identification in a timely manner, irrespective of whether they caused actual harm. Ensure that all reported incidents are appropriately reviewed, managed and investigated based on their severity within NHS Doncaster CCG and commissioned services. Describe the arrangements for serious incident management, investigation and follow up action. Learn, make changes and ensure improvements, as a result of all incidents in order to improve safety for patients, staff, visitors and contractors. Use qualitative and quantitative data analysis to highlight any trends which may be occurring and uncover any further need for intervention. Ensure individual and organisational responsibilities are defined and followed for incident and serious incident reporting. Ensure the organisation complies with all current legislation and performance management. Identify the assurance process in place for monitoring and reviewing serious incidents involving services commissioned by Doncaster CCG. Ensure all commissioned services adhere to contractual performance requirements. 1.3 The purpose of this document is to provide guidance to all NHS Doncaster CCG Staff in relation to the reporting of Incidents and Serious Incidents. It will also provide guidance as to how the Incidents should be managed. 1.4 The document also provides guidance to NHS Doncaster CCG staff in relation the Performance management of Serious Incidents that occur within commissioned services. 1.5 The aims of this procedural document policy are: 8

To ensure that incidents that occur within the CCG are reported and managed in a timely effective manner that is in line with national requirements, guidance and legislation. To ensure that the CCG meets its obligations to performance manage Serious Incidents that occur within the services it commissions and that in meeting this obligation, all national and local guidelines and legislation is followed. To ensure that there are robust processes in place to disseminate appropriate learning from incidents and reduce the risk of reoccurrence through a positive culture of learning and continuous quality improvement. To ensure that there are strong governance arrangements in place within the CCG in relation to patient safety and the management of incidents across the health community and within the organisation. 1.6 To ensure continuous improvement in risk management, the organisation has a range of key performance indicators (KPIs) which it uses for monitoring purposes: No. Key Performance Indicator Method of Assessment 1. Serious Incident Reporting Performance and Analysis 2. Internal Incident Reporting and analysis. 3. Production of trends, themes and patterns reports based on information from Providers 4. Monitor performance of providers in relation to learning and progress of action plans to ensure they are completed in accordance with original plan I. Incident management Forum Minutes and Performance management records. II. Contract monitoring and reports to IMF and relevant committees I. Quarterly Corporate Assurance Report. I. Receipt of annual reports from Providers. II. Quarterly and annual reporting within Doncaster CCG Governance structures. I. Through information schedule and reporting to NHS Doncaster CCG. II. Minutes and papers considered through Clinical Quality Review Group. 9

2. LEGISLATION AND GUIDANCE 2.1 The following legislation has been taken into consideration in the development of this policy and procedure: Health and Safety at Work Act 1974 The Management of Health & Safety at Work Regulations 1999 Mental Health Act 1983 and 2007 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 Human Rights Act 1998 Data Protection Act 1998 The Children Act 2004 Mental Capacity Act 2005 2.2 The following guidance has been used in the development of this policy and procedure: An Organisation with a Memory DOH 2000 Doing Less Harm DOH and NPSA 2001 Seven Steps to Patient Safety NPSA Building a Safer NHS for patients Implementing An Organisation with a Memory DOH 2001 Learning from Bristol DOH 2002 Design for Patient Safety DOH 2005 Safety First: A report for patients, clinicians and healthcare managers DOH 2006 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013(RIDDOR) Information Commissioner Guidance Documents. Reporting Safety Problems for Medicines, Blood and Devices MHRA. www.mhra.gov.uk Health and Safety Executive (HSE) Reporting www.hse.gov.uk Safety Problems for medicines, Blood and Devices medicines Healthcare products Regulatory Agency (MHRA) Reporting, www.mhra.gov.uk Counter Fraud and Security Management Services (CFSMS) - Physical assault reporting NHS Estates Reporting fire related incidents NHS Litigation Authority (NHSLA) Requirements Procedure for the management of Serious Incidents (SIs) Framework NHS Commissioning Board March 2013. Being Open When Patients are Harmed NPSA September 2005 (relaunched 2009) The Private and Voluntary Health Care (England) Regulations 2001 Statutory Notifications Guidance HCC) 2006 A guide to Good Practice in the Management of Controlled Drugs in Primary Care (England) February 2007 Memorandum of Understanding - Investigating Patient Safety incidents involving unexpected death and serious harm: a protocol for liaison and effective communications between the NHS, Association of Chief Police Officers and Health and Safety Executive February 2006 10

Guidelines for the NHS in support of the Memorandum of Understanding November 2006 Working together to Safeguard Children 2013 No Secrets Guidance on developing and implementing multi-agency procedures to protect vulnerable adults from abuse The never events list 2013/14 Update. Francis Report report of the Mid Staffordshire NHS Foundation Trust 2013. Keogh Report Review into the quality of care and treatment provided by 14 Trusts in England 2013. Winterbourne Report Transforming Care: A National response to Winterbourne View Hospital 2012 Berwick Report - A promise to learn A commitment to act: Improving the safety of patients in England 2013 Serious Incident Framework NHS England 2013. Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents requiring Investigation (IG SIRI) HSCIC 2014. 2.3 The Essential Standards of Quality and Safety (March 2010) consist of 28 regulations (and associated outcomes) that are set out in two pieces of legislation: the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010) and the Care Quality Commission (Registration) Regulations 2009. 3. SCOPE 3.1 This policy applies to those members of staff that are directly employed by NHS Doncaster CCG and for whom NHS Doncaster CCG has legal responsibility. For those staff covered by a letter of authority/honorary contract or work experience this policy is also applicable whilst undertaking duties on behalf of NHS Doncaster CCG or working on NHS Doncaster CCG premises and forms part of their arrangements with NHS Doncaster CCG. As part of good employment practice, agency workers are also required to abide by NHS Doncaster CCG policies and procedures, as appropriate, to ensure their health, safety and welfare whilst undertaking work for NHS Doncaster CCG. 4 ACCOUNTABILITY AND RESPONSIBILITIES 4.1 Overall accountability for incident management within the organisation lies with the Chief Officer who has responsibility for establishing and maintaining an effective risk management system within the organisation including sharing lessons learnt. This is formally delegated at follows: Chief Nurse (or equivalent) Has delegated responsibility for: Leading the development of appropriate systems and processes to manage Serious Incidents in line with the CCGs responsibilities. 11

Chief Of Corporate Services Chief Of Finance Nominated Head of Quality in Contracts and Adult Safeguarding Lead Quality Support Officer Staff Has delegated responsibility for the development and implementation of non-clinical incident management. This is the Senior Information Risk Owner (SIRO) for NHS Doncaster CCG. Has delegated responsibility for the development and implementation of financial risk management and financial governance. Has delegated responsibility for the day to day management of the serious incident reporting, reviewing and performance monitoring process. Will liaise with other Heads of to ensure that incidents will be managed appropriately. Also acting as liaison between Doncaster CCG and Rotherham, Doncaster and South Humber Mental Health NHS Foundation Trust (RDaSH) and Doncaster and Bassetlaw Hospitals NHS Foundation Trust (DBHFT) with respect to clinical incidents. Has delegated responsibility for the logging, updating and extracting information on the Serious Incident Database. Said person will provide the Incident Management Forum and Quality and Safety Committee with the relevant reports and will liaise with the Area Team to ensure information is received/provided and recorded accurately. Responsibilities of Staff (including all employees, whether full/part time, agency, bank or volunteers) are: Complying with all procedural documents of the organisation. Identifying any gaps in Incident management Policies and identifying these to the document authors / responsible officers. 4.2 The day-to-day operation of commissioned service incident reporting has been delegated to the Head of Quality in Contracts and Adult Safeguarding Lead unless otherwise agreed. Said person (or their delegates) will provide NHS Doncaster CCG Quality and Safety Committee relevant information in respect of all types of incidents. 4.3 All staff must take charge of the immediate situation until a more senior person is available and ensure that all potential/actual incidents (including serious incidents) are reported, that the incident report is fully completed and that the requirements of this policy and procedure are met. In the first instance, the incident must be reported within 24 hours. Where appropriate staff members may be involved in the review of incidents and implementing actions. 4.4 All staff must ensure they book on and attend any mandatory or statutory training sessions on Risk Management, Incident Reporting and Health & Safety. 12

4.5 All Managers All managers are responsible for ensuring that all incidents (including serious incidents), which occur in their areas of responsibility, are reported immediately through the agreed reporting systems. Said incidents must also be reviewed by the appropriate directorate strand manager/reviewing Manager to ensure that: The incident report is fully and accurately completed The incident severity has been correctly categorised Reports to External Agencies are completed and sent Where appropriate managers must ensure an investigation is carried out. Managers are responsible for ensuring staff at all levels understand the need to report all incidents, accidents and near misses as per this policy and procedure and to ensure compliance with NHS Doncaster CCG s legal obligations. In order to discharge this duty managers are required to ensure that members of staff attend any mandatory or statutory training sessions on risk management and health & safety. It is recognised that many incidents; especially more serious incidents (Serious Incidents) may have a significant impact upon staff affected by the incident. Arrangements should be made by Line Managers to ensure that any member of staff involved in incidents receives the necessary support and counselling (if required). 4.6 A nominated Lead Investigator has delegated responsibility for undertaking the investigation using the NPSA Root Cause Analysis model and submitting a full report within the specified timescales. http://www.nrls.npsa.nhs.uk/resources/type/toolkits/ 4.7 All Chiefs are collectively and individually responsible for the management of risk and for implementing this policy and procedure. It is each and all, Chiefs responsibility to ensure that departmental inductions outline the organisation s requirements of staff in respect of this policy and procedure. Chiefs also have responsibility for cascading information to staff regarding updates or amendments to the policy and procedure. 4.8 Committees The Clinical Commissioning Group Governing Body has delegated responsibility for reviewing the development and implementation of risk management systems to the Quality and Safety Committee. In order to discharge this duty the Quality and Safety Committee must ensure that appropriate subcommittees and groups exist to support the process.. The following sub-committees provide assurance that incidents are being managed and confirm action plans resulting from incidents (including serious incidents), complaints or claims are followed up and lessons learnt are disseminated: - 4.9 Incident Management Forum (IMF) reviews, quality assures and on completion of required actions and agrees closure of all serious incidents reported by NHS Doncaster CCG commissioned services. The IMF may also undertake this role under a memorandum of understanding when incidents occur in services commissioned by others including Public Health and NHS England. 13

4.10 Clinical Quality Review Group reviews themes and trends and any recommendations from the IMF to escalate any issues/concerns identified. 5. DISSEMINATION, TRAINING AND REVIEW 5.1 Dissemination 5.1.1 The effective implementation of this policy will support openness and transparency. NHS Doncaster CCG will ensure that the policy is implemented through the publication of this policy, supporting any training needs and the also the monitoring of the Key performance indicators. 5.1.2 This policy is located in the General Policy Manual. A set of hardcopy Procedural Document Manuals are held by the Governance Team for business continuity purposes and all procedural documents are available via the organisation s website. Staff members are notified by email of new or updated procedural documents. 5.2 Training 5.2.1 All staff will be offered relevant training commensurate with their duties and responsibilities. Staff requiring support should speak to their line manager in the first instance. Support may also be obtained through the HR Department. Managers should contact the Governance Team if there are specific training needs. 5.2.2 It is important that all staff working for the organisation are familiar with this policy and that it is well understood and that the associated procedures are rigorously applied. Some staff have been trained in the NPSA Root Cause Analysis techniques by the organisation, this will be dependent on their role in incident investigation 5.3 Review 5.3.1 This policy will be reviewed regularly and in accordance with the following on an as and when required basis: Legislative changes Good practice guidance Case law Significant incidents reported New vulnerabilities Changes to organisational infrastructure This policy is located on the Website/Extranet. A number of other procedural documents and policies are related to this policy and should be read in conjunction as shown below: Relevant Health & Safety Policies 14

Claims Management Policy Whistleblowing Policy Risk Management Strategy, Policy and Procedure Security Policy Doncaster CCG Complaints Policy Disciplinary Policy Relevant Infection Prevention & Control Policies Freedom of Information and Environmental Regulations Policy Practice Guidance for Safeguarding Children This list is not exhaustive and other NHS Doncaster CCG policies may relate to this policy. 15

SECTION C - PROCEDURE 1. PROCEDURE IN THE EVENT OF AN INCIDENT (INCLUDING SERIOUS INCIDENTS) OCCURRING WITHIN THE CCG. 1.1 Immediate action should be taken to ensure the health needs of the individuals affected are dealt with in order to minimise harm and limit the impact of the incident if safe to do so. The most senior relevant person should also be informed. 1.2 Should any situation pose imminent danger to others, attempts should be made to reduce the risk to the environment, staff patients and the public (i.e. first aid, emergency services, administering drugs, isolation of area, wearing protective clothing etc). 1.3 Immediate notification to external agencies such as the Police or Coroner should be considered when appropriate and following advice from the Chief of Corporate Services or Deputy. 1.4 Documenting and reporting the incident is done by completing the Incident Reporting Form (Appendix D). This form should be completed within 24hrs of the incident taking place. 1.5 The completed form is reviewed by the Chief of Corporate Services (or deputy) and an initial risk assessment is undertaken. This initial assessment will include any immediate actions required and also if the incident has met the threshold to be considered a Serious Incident. Advice is available from the Chief Nurse or the Head of Quality in Contracts. 1.6 If the incident has not reached the threshold to be considered a Serious Incident, the Chief of Corporate Services will determine what further actions are required to investigate the incident and identify any appropriate learning. 1.7 Learning from incidents will be used to make any necessary changes within the CCG and to mitigate the risk to individuals and the organisation. 1.8 If the incident has met the threshold to be considered a Serious Incident, the process to be followed should be in line with the NHS England Serious Incident Framework. 2. PROCEDURES IN RELATION TO SERIOUS INCIDENTS. 2.1 Any incident considered as a serious Incident will need to be recorded on STEIS (Strategic Executive Information System). This recording will be carried out by the Quality and Patient Safety Team. 2.2 Certain Government agencies or statutory bodies require notification of certain incidents. The main agencies that require notification are listed below: Health & Safety Executive (HSE) - RIDDOR NHS Estates Medicines and Healthcare Regulatory Agency (MHRA) Police 16

Fire Coroner Doncaster CCG Quality Team Information Commissioner s Office It is recommended that specialist advice regarding external reporting is sought from the Head of Health, Safety and Security at the Commissioning Support Unit (CSU) and Chief of Corporate Services. 2.3 NHS England will also need to be informed of any Serious Incident reported by NHS Doncaster CCG. NHS England has the responsibility of performance managing any CCG Serious Incident. 2.4 A person responsible for contacting relevant parties (i.e. staff, patient(s), carer(s), relative(s), public, visitor, and contractor) should be identified. It must be noted that any individuals involved in incidents, including relatives, must be informed. 2.5 Appropriate support and information should be made available to those involved in the incident. 2.6 The Incident will be investigated and managed in line with the NHS Serious Incident Framework and follow Root Cause Analysis methodology. 2.7 The appropriate people or person to lead and undertake any investigation will be identified by NHS Doncaster CCG Senior Management Team after considering the nature of the incident, skills required to investigate and any potential conflicts of interest. 2.8 NHS Doncaster CCG will ensure that it has access to appropriately skilled and relevant staff to be able to undertake robust and transparent investigations. 2.9 The Incident Management Forum of NHS Doncaster CCG will provide internal assurance of the Incident report within the required timescales. 2.10 Final NHS Doncaster CCG sign off will be by the Chief Operating Officer or nominated deputy. 2.11 A final report will be made to NHS England within the time scales identified within the NHS England Serious Incident Framework. 2.12 Any learning from the investigation and subsequent Action plans will be monitored through the Quality and Safety Committee. 3. TRENDS AND LESSONS LEARNT 3.1 Serious incident trends, themes, patterns and lessons learnt will be analysed and reported to the appropriate committees. Lessons learnt will be disseminated appropriately across the health community and to other relevant groups to minimise the risk of reoccurrence. 17

4. SERIOUS INCIDENTS INVOLVING A DONCASTER CCG COMMISSIONED SERVICE 4.1 Doncaster CCG has the responsibility for ensuring that serious incidents are appropriately reported and managed for any service which it commissions for NHS patients. This responsibility is discharged through continued arrangements with providers. 4.2 All incidents considered Serious Incidents should be reported in line with the current NHS England Serious Incident Framework. 4.3 Full report, including Root Cause Analysis or other similar investigation process and action plan will be provided in line with the Framework. There may be occasions when more time is required e.g. awaiting the outcome of a criminal investigation, but this will be decided on a case by case basis. 4.4 All providers are contractually required to report all Serious Incidents occurring within their organisation on STEIS. 4.5 If the provider does not have access to STEIS, they are required to inform NHS Doncaster CCG of the incident and the Quality and Patient Safety Team can input the incident on STEIS. 4.6 It is important that the organisation appropriately responds to the potential for media interest in a particular incident. A Serious Incident may trigger the preparation of a media response based on the available information by the appropriate Chairperson, Chief Operating Officer and the Head of Communications. All media communications must be led by and approved by the Head of Communications. 4.7 Where potential media interest exists, the appropriate Chief should be notified even if the incident was not previously considered to be a Serious Incident. 18

SECTION D NHS DONCASTER CCG SERIOUS INCIDENT PERFORMANCE MANAGEMENT PROCEDURES 1. PERFORMANCE MONITORING THE MANAGEMENT OF SERIOUS INCIDENTS (EXCEPT CHILD SAFEGUARDING INCIDENTS) 1.1 As a lead commissioning organisation, Doncaster CCG has a specific duty to provide assurance for the reporting and management of serious incidents occurring at their main providers, commissioned services, foundation trusts, independent care providers etc. This will be discharged through the following procedure; The Serious Incident notification is received via STEIS and logged on the Doncaster CCG Serious Incident Database. Ensure NHS England Area Team have been notified in the case of the following types of incident:- Outbreaks of infectious diseases including Pandemic Flu outbreak Child aged 17 or under being admitted to adult mental health bed Serious incidents involving Trainee Doctors Never events Homicide involving a service user Incidents relating to NHS England commissioned services Identify Trust Lead for investigation and advise the service involved of the target for submission of investigation report and the need to update on a monthly basis. Exceptions will only be considered in the case of a Police, Coroner investigation and extenuating circumstances. Requests for extensions should be submitted in writing/email. If an interim report is submitted, ensure monthly updates are received until a final report is submitted (even if it is to say there is no further progress). Once a full report is received, submit to Incident Management Forum who will review the report. The report will be rated appropriately and feedback to the lead investigator. If the Incident Management Forum agrees the report as being unsatisfactory it is returned to the local trust lead for further information within a specified timescale. If the Incident Management Forum recommends the report for closure it is closed on STEIS. All associated actions are monitored through the Acute Clinical Quality Review Group (unless otherwise agreed by the Incident Management Forum). Lessons learnt need to be included within the STEIS form prior to closure to allow for shared learning across the Regional teams 19

1.2 In principle NHS Doncaster CCG should share information with NHS England in an open and transparent way to facilitate appropriate management and communication. 1.3 In the case of a Serious Incident involving mental health service users committing homicide, Doncaster CCG will follow the NHS England Single Operating Framework in relation to Investigating Mental Health Homicides. 1.4 NHS Doncaster CCG will work with NHS England as required to facilitate and support any independent investigations that are required. 2. PERFORMANCE MONITORING THE MANAGEMENT OF CHILD SAFEGUARDING SERIOUS INCIDENTS 2.1 Where the incident involves a child or younger person, considerations should be given to raising the alert as a Serious Incident. The following process should be undertaken by NHS Doncaster CCG when monitoring the management of child safeguarding serious incidents that have occurred within Doncaster. The child safeguarding serious incident is received and logged on STEIS using the notification report and NHS Doncaster CCG Serious Incident database within 24 hours of being alerted. Identify and log the investigator on the Serious Incident database. Inform the Designated Nurse of the target for completion of investigation report date in writing and the need to update on a monthly basis. Ensure the Designated Nurse updates in relation to any significant developments. Once the Safeguarding Process is complete and relevant reports produced, the CCG will consider the closure of the incident through the Incident Management Forum. If the Incident Management Forum agrees the report as being unsatisfactory it is returned to the local trust lead for further information within a specified timescale. If the Incident Management Forum recommends the report for closure it should be submitted to NHS England Local Area Team via the Safe Haven e-mail address. A request to close the Serious Incidents is submitted to the Area Team. 3. MONITORING SERIOUS INCIDENT TRENDS, THEMES AND PATTERNS 3.1 Serious incident trends, themes, patterns and lessons learnt will be analysed and reported to the appropriate committees and NHS England Local Area Team via STEIS. 20

3.2 In cases where there is evidence that the incident is part of a worrying trend or where the circumstances or consequences of the incident are exceptionally serious, NHS Doncaster CCG may need to instigate a wider investigation. Doncaster CCG may ask the Trust to undertake further inquiries or suggest a particular course of action. Or may decide that a more independent investigation of the incident in required and work with the Trust to facilitate this. 4. OBTAINING ASSURANCE OF ACTION PLAN COMPLETION 4.1 Doncaster CCG will gain assurance by exception on each Provider s serious incident action plans to determine whether all actions have been completed in accordance with the plan. 4.2 Performance management of Provider Action plans will take place within the existing contractual and governance structures and process. 5. REPORTING ON NEVER EVENTS 5.1 Doncaster CCG will monitor the occurrence of Never Events within the services they commission. Providers are required to publish information on the occurrence of never events as part of their annual Quality Account. The reporting of never Events and associated actions will be in line with the current published guidance at the time. 21

APPENDIX A USEFUL CONTACTS Doncaster CCG Directorate of Quality and Patient Safety Chief Nurse 01302 566216 Chief of Corporate Services 01302 566034 Head of Quality in contracts and Designated Nurse for Safeguarding Adults 01302 566211 Designated Nurse for Safeguarding & LAC 01302 566276 Quality and Contracts Manager 01302 566056 Named Nurse for Safeguarding Adults and Quality 01302 566114 Quality Support Officer 01302 566054 Safe Haven Fax Doncaster CCG 01302 556321 Other agencies / bodies Reporting Safety Problems for Medicines, Blood and Devices MHRA www.mhra.gov.uk. Health and Safety Executive (HSE) Reporting including RIDDOR www.hse.gov.uk or 0845 300 99 23 NHS Commissioning Board Special Health Authority www.england.nhs.uk/ Local Counter Fraud Specialist (LCFS) Reporting assaults www.cfsms.nhs.uk Legal Advice via Directorate of Corporate Services Care Quality Commission www.cqc.org.uk or 03000 616161 NHS Property Services- www.property.nhs.uk/ Monitor - www.gov.uk/government/organisations/monitor Information Commissioner Office www.ico.gov.uk email: casework@ico.gsi.gov.uk 22

Reportable External Bodies APPENDIX B Type of Incident Method Report To / From Timescales RIDDOR: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 On-line / by telephone. Information to be supplied to the Head of Human Resources who will contact external agencies. http://www.riddor.gov.uk/ 0845 300 99 23 Line Manager to Head of Human Resources. Head of Human Resources to report to Health and safety Executive. Health and Safety Executive Edgar Allen House 241 Glossop Road, Sheffield, S10 2GW Line Manager to report: Deaths/Major injuries/dangerous occurrences/ Diseases immediately Injury resulting in absence from work for over 3 days within 10 days Within 10 days Admission of a patient/visitor into A&E due to an injury-immediately Incidents that may lead to litigation Telephone Line Manager to report to Chief of Corporate Services (Claims) Chief of Corporate Services (Claims) to: NHS Litigation Authority 5 Pemberton Row London EC4A 3BA Line Manager: Chief of Corporate Services (Claims) As soon as risk of possible litigation identified Chief of Corporate Services (Claims): NHS Litigation Authority Within 48 hours of notification For incidents relating to buildings, plant and nonmedical equipment (dependent on type and severity) Telephone Line Manager to Health of Health, Safety & Security Head of Health, Safety & Security to: NHS Estates Dept of Health 1 Trevelyan Square Boars Lane Leeds LS1 6A 23 Line Manager to report to: Head of Health Safety & Security Immediately Head of Health Safety & Security to report to: NHS Estates Within 24 hours

Type of Incident Method Report To / From Timescales Physical Assault Online reporting system Head of Health Safety & Security (Doncaster CCG) via reception to: NHS Counter Fraud & Security Management Services Weston House, 246 High Holborn, London, WC1V 7EX Head of Health Safety & Security (Doncaster CCG) via reception to: NHS SMS Within 5 working days of notification of the incident report Fire - any incident, no matter how small, involving fire or fire warning systems, or false alarm, resulting in Fire Brigade attendance should also be reported using the Fire Safety Policy. Online reporting system & documentation in the fire manual. A copy of the latter should be sent to the fire officer with the original kept in the fire log book Fire Officer (Doncaster CCG) Corporate Governance Sovereign House Ten Pound Walk DN4 5HZ As per fire policy Line Manager to report to: Chief of Corporate Services Doncaster CCG) Immediately Head of Health Safety & Security to: Fire Officer Within 24 hours Information Governance Incidents Online reporting system and telephone If it is likely to be a Serious Incident (IG SIRI) then the Corporate Governance Manager should be consulted. Corporate Governance Manager to report to the Information Commissioners Office as appropriate Line Managers to report Serious Incidents to: Corporate Governance Manager Immediately Fatality - apparent or potentially as a consequence of alleged patient action; self-harm or contributory action by staff. Online reporting system and Email or in case of very serious incident telephone STEIS NHS Doncaster, Patient Safety Team Within 24 hours of incident Within 1 working day 24

Continual monitoring by Quality Team APPENDIX C Serious Incident Performance Monitoring Flowchart NHS DONCASTER DBHFT Independent Care Providers RDASH SERIOUS INCIDENT Reported & Logged Clock starts Local Trust lead the investigation NHS Doncaster generate reminder or request for further information NHS Doncaster inform trust in writing of target date for completion, of investigation and report Investigation Report to Incident Management Forum (IMF) Full Report Exception Report No available Report Unsatisfactory Report with no evidence of sharing and learning outcomes Satisfactory Report with evidence of sharing learning outcomes Reporting in Line with NHS England Serious Incident Framework IMF to agree closure where appropriate Closure request for NHS Doncaster CCG Serious Incidents to 25 be agreed by NHS England Area Team

APPENDIX D NHS DONCASTER CCG INCIDENT REPORTING FORM Incident reporter details Name: Role: Date reported: Incident description What happened? Describe the incident. (please record facts only, not opinion) When did the incident happen? (please enter date and time if known) Where did the incident happen? (describe the location) Who was involved in the incident and who saw (witnessed) the incident? Were there any adverse effects? (record injuries, financial costs, loss of service, reputational impact etc) 26

Post-incident actions What actions were taken after the incident? Are any further actions planned? Incident type (mark only 1 box) Mark Onwards reporting Accident / Injury Communication -------- Confidentiality / Information Governance -------- Disruptive or Violent behaviour / Assault RIDDOR: Health & Safety Executive (via HR) Physical Assault on Staff: NHS Security Management Service (via CSU) Estates / Facilities / Security / Health & Safety -------- Financial loss -------- Patient Safety Other (please specify -------- National Patient Safety Agency (via Corporate Governance Team) Other Do you want to tell us anything else? Please return the completed form as soon as possible after the incident to: Corporate Governance Team, Sovereign House, Ten Pound Walk, Doncaster, DN4 5DJ Or by email to alison.hague@doncasterccg.nhs.uk Office use only Date received Logged 27