POLICY ON THE REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURRENCES

POLICY ON THE REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURRENCES Policy Details NHFT document reference HSC009 Version Version 2 25.03.2014 Date Ratified 06.05.2014 Ratified by Trust Policy Board Implementation Date 06.05.2014 Responsible Director Director of Corporate Support Review Date 30.04.2016 Related Policies & other documents HSC001 Health and Safety Policy, CRM002 Incident Policy Freedom of Information category Policy 1 of 15 Implementation Date: 06.05.2014

TABLE OF CONTENTS 1. DOCUMENT CONTROL SUMMARY... 3 2. INTRODUCTION... 4 3. PURPOSE... 4 4. DEFINITIONS... 4 5. DUTIES... 5 5.1. Trust Managers... 5 5.2. Health and Safety Risk Manager... 5 5.3. Employees... 5 6. POLICY PROCESS... 5 6.1. Accidents Reportable Under RIDDOR... 5 6.1.1. Major injury... 5 6.1.2. Diseases... 6 6.1.3. Dangerous occurrences... 6 6.2. Initial Procedure following a Dangerous Occurrence... 7 6.3. Reporting a RIDDOR accident... 7 6.4. Investigating the RIDDOR... 7 6.5. Records... 9 6.6. Further Action... 9 7. TRAINING... 9 7.1. Mandatory Training... 9 7.2. Specific Training not covered by Mandatory Training... 10 8. MONITORING COMPLIANCE WITH THIS DOCUMENT... 10 9. REFERENCES AND BIBLIOGRAPHY... 10 10. RELATED TRUST POLICY... 10 APPENDIX 1 - RIDDOR INVESTIGATION REPORT FORM... 11 2 of 15 Implementation Date: 06.05.2014

1. DOCUMENT CONTROL SUMMARY Document Title Document Purpose (executive brief) Status: - New / Update/ Review Areas affected by the policy Policy originators/authors Consultation and Communication with Stakeholders including public and patient group involvement To ensure all major injuries, diseases and dangerous occurrences are reported to the enforcing authority Review All areas, Trust-Wide Tina Perkins Health and Safety Risk Manager Safer Services and Environment Group Archiving Arrangements and register of documents Equality Analysis (including Mental Capacity Act 2007) Training Needs Analysis See section 7 The Trust Policy Lead is responsible for the archiving of this policy and will hold archived copies on a central register See Appendix 2 Monitoring Compliance and See section 8 Effectiveness Meets national criteria with regard to NHSLA N/A NICE N/A NSF N/A Mental Health Act N/A CQC N/A Other Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 Health and Safety at Work etc Act 1974 Further comments to be None considered at the time of ratification for this policy (i.e. national policy, commissioning requirements, legislation) If this policy requires Trust Board TPB ratification please provide specific details of requirements 3 of 15 Implementation Date: 06.05.2014

2. INTRODUCTION The Reporting of Injuries, Regulations (RIDDOR) 2013 came into force in April 2013. These regulations put arequirement on the Trust to insure that certain major injuries, occupational diseases and dangerous occurrences that occur as a result or in connection with the work done in the Trust, are reported to the Incident Contact Centre (ICC). The Regulations require that when a RIDDOR occurs that the ICC are informed as soon as possible using the online reporting system (a telephone service remains for reporting fatal and specified injuries only) The information on reported accidents enables the Health and Safety Executive to identify where and how risks arise and to investigate serious accidents. It is a legal requirement to report a RIDDOR and failure of such could lead to prosecution. 3. PURPOSE The aim of this policy is to ensure that where certain specified injuries, diseases or dangerous occurrences have occurred due to the Trusts activities then they are reported to Incident Contact Centre as required by the Reporting of Injuries, Regulations 2013. 4. DEFINITIONS Accident An event leading to loss, injury or damage. Also includes an act of non-consensual violence done to a person at work. HSE The Health and Safety Executive. These are the enforcing authority for the Trust on Health and Safety matters. ICC - Incident Contact Centre. The ICC is the reporting service for all work related health and safety accidents. The ICC send the information gathered to the HSE. Incident An event where there is no shown damage, injury or loss but which may have had serious consequences. Near Miss An event that could have, but did not, lead to loss injury or damage. NHFT - Northamptonshire Healthcare NHS Foundation Trust 4 of 15 Implementation Date: 06.05.2014

RIDDOR Reporting of Injuries, Regulations. 5. DUTIES 5.1. Trust Managers Must familiarise themselves with this policy and ensure that all RIDDORs are reported to the Risk Management Department as soon as it is known that there is one. They must investigate all RIDDORs to identify the cause(s) and to try to prevent re-occurrence. The form used for such investigations is available from the Risk Management Department, on the health and safety page of the intranet and attached in Appendix 1. Trust managers must also ensure that RIDDORs are reported in the same way as all adverse incidents using the Incident Reporting System DatixWeb. Full details of this requirement are given in CRM002 Policy for the Management of Incidents. 5.2. Health and Safety Risk Manager Will notify the ICC by the quickest practicable means of the RIDDOR. The health and safety risk manager will also keep records of all RIDDORs and provide assistance in investigations as required. 5.3. Employees Must co-operate with the Trust on matters relating to this policy and assist on providing information for the investigation as required. They must also notify management of any known RIDDOR that may not have been reported. 6. POLICY PROCESS 6.1. Accidents Reportable Under RIDDOR The following are all accidents that are reportable under RIDDOR: 6.1.1. Specified injury Examples include (resulting out of or in connection with work): Death Any fracture, other than to fingers, thumbs or toes. Any amputation. 5 of 15 Implementation Date: 06.05.2014

Any injury likely to lead to permanent loss of sight or reduction in sight in one or both eyes Any crush injury to the head or torso, causing damage to the brain or internal organs Any burn injury (including scalding) Any degree of scalping requiring hospital treatment Any loss of consciousness caused by head injury or asphyxia Any other injury arising from working in an enclosed space Any other injury resulting out of or in connection with work: Where a person is incapacitated for work that they may be reasonably expected to do in their normal course of duties for more than seven consecutive days (note the individual does not need to be absent from work only incapacitated from normal duties). To any member of the public that results in their admittance to hospital. 6.1.2. Diseases These must be notified by the employee with a medical certificate and linked to the work area. Examples include: Cramp of the hand or forearm due to repetitive movements associated with work involving prolonged periods of handwriting, typing or other repetitive movements of the fingers, hand or arm. Carpel tunnel syndrome. Hand-arm vibration syndrome. Tendonitis or tenosynovitis Occupational Dermatitis Occupational asthmaregulation 9 requires employers and self-employed workers to report cases of occupational cancer, and any disease or acute illness caused by an occupational exposure to a biological agent. 6.1.3 Dangerous occurrences These are high risk incidents and even if no-one is injured must be reported as a RIDDOR. Examples include: The failure of any load-bearing part of any lift or hoist. The failure of any pressure vessel that has the potential to cause death of any person. Pressure vessels include boilers and gas cylinders. An explosion or fire on any premises which cause suspension of normal work for more than 24 hours. 6 of 15 Implementation Date: 06.05.2014

6.2. Initial Procedure following a Dangerous Occurrence The Trust Manager will ensure that for their area of responsibility the following arrangements are in place in the event of a Dangerous Occurrence: If required first aid is administered and an ambulance is called for. The area of the Dangerous Occurrence is vacated. Assess the area to ensure it is safe to enter. Prohibit access to the area so it remains undisturbed i.e. doors secured, and warning notices posted or area is cordoned of and supervised. The use of any work equipment/plant involved is prohibited and, if safe to do so, any potentially dangerous or faulty machinery is isolated from its power supply. The area is not disturbed, as far as is possible, until a Director has been consulted and the incident is thoroughly investigated and accurate records kept. If required the Dangerous Occurrence may be classed as a Major Emergency. Full details of major emergencies and procedures are given in the Major Incident/Emergency Plan and Business Continuity Arrangements. 6.3. Reporting a RIDDOR accident The Trust Manager will ensure that for their area of responsibility: All accidents, diseases, dangerous occurrences and near misses are recorded onto DatixWeb as soon as possible. All accidents managers assess as potentially reportable under RIDDOR are reported to the Health and Safety Risk Manager immediately or as soon as is practicable by telephone or email and where relevant other managers made aware. Upon receipt of the necessary information the Health and Safety Risk Manager will report the accident to the ICC. 6.4. Investigating the RIDDOR The relevant Trust Manager must ensure that: They thoroughly investigate all incidents reportable under RIDDOR immediately. All records relating to such incidents are carefully completed and filed. Information on what records must be kept is given below. A copy of the completed RIDDOR Investigation should be submitted to the Health and Safety Risk Manager, line manager and relevant Director within 30 days. When investigating an accident the relevant Trust Manager should attempt to gather as much information as possible. It is vital that as much information as possible is collected and sent to the Health and Safety Risk Manager with the investigation as it may later be required as 7 of 15 Implementation Date: 06.05.2014

evidence in any compensation claims or prosecution charges. Such information can include: Photographs/Sketches of the area or any equipment involved (include measurements if possible). If any photographs are required of patients their consent should be obtained first. Interview any witnesses and, where possible, the injured person, as soon after the incident as is practical, and take a written signed statement. Identify and obtain any relevant risk assessments and records, including maintenance and training records. The aims of an investigation are to find out: What happened? What caused the accident? Who was involved? When it occurred? Where it occurred? How could it have been prevented? What needs to be done to prevent a recurrence? When investigating the incident the relevant Trust Manager should consider what factors that may have been lacking and so contributed to the cause. Such factors are: Managerial Factors Are the Health and Safety Policy and other policies relevant to the incident implemented successfully? Are risk assessments suitable and sufficient? Are health and safety responsibilities clear? Are there any safe systems of work? What other preventative measures are in place? Are there adequate resources available? Occupational Factors What plant and equipment was being used? Is it well maintained? What hazardous substances were being used? What was the work activity? Environmental Factors Was it a work or public area? Is the lighting suitable? Any distractions from noises? Any wet or slippery surfaces? Any other environmental conditions that may have contributed to the event? Personal Factors What was the personal behaviour of the individuals involved? Were there any violations of procedures? Did the individual have any disabilities? 8 of 15 Implementation Date: 06.05.2014

What training had the individual received? Is all mandatory training relating to those involved up to date e.g. induction, manual handling etc 6.5. Records The relevant Trust Manager will ensure that all RIDDOR forms and accident reports are fully completed at the time of the incident and sent to the Health and Safety Risk Manager. The following records will be kept for a minimum of three years. DatixWeb reports; Investigation report and Photographs; First aid given; Completed RIDDOR report; Documents relating to previous accidents; Relevant risk assessments; Relevant maintenance and training records; Relevant method statements and work procedures If any correspondence is received from anyone claiming injury this must be sent immediately to the Head of Risk Management and Patient Safety and confirmation of receipt obtained. Do not enter into any correspondence as this will be dealt with by the Head of Risk Management and Patient Safety. A central record must be kept of all accident and first aid treatment records. These must be retained for a minimum of three years, and then archived. 6.6. Further Action The relevant Trust Manager will ensure that where the investigation shows the incident could have been prevented, action is taken to implement the necessary controls for prevention. The action required should be recorded in the Risk Register (see HSC002 Policy and Guidance on the Use of Risk Registers). If the investigation identifies an incident, which could occur on other premises, this information must be reported to the relevant Director. 7. TRAINING 7.1. Mandatory Training There is no mandatory training associated with this policy. 9 of 15 Implementation Date: 06.05.2014

Training required to fulfil this policy will be provided in accordance with the Trust s Training Needs Analysis. Management of training will be in accordance with the Trust s Statutory and Mandatory Training Policy 7.2. Specific Training not covered by Mandatory Training Not applicable to this document Ad hoc training sessions based on an individual s training needs as defined within their annual appraisal or job description. 8. MONITORING COMPLIANCE WITH THIS DOCUMENT The table below outlines the Trusts monitoring arrangements for this document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Duties All RIDDORs reported and investigated All RIDDOR investigations completed, documentation submitted, learning identified and implemented Method of monitoring Individual responsible for the monitoring Monitoring frequency To be addressed by the monitoring activities below. Review of incident records Review of RIDDOR incidents Service managers managers Health and Safety Risk Manager Monthly Monthly Group or committee who receive the findings or report Departmental/ service meetings Safer Services and Environment Group Group or committee or individual responsible for completing any actions Safer Services and Environment Group Safer Services and Environment Group Training will be monitored in line with the Statutory and Mandatory Training Policy. 9. REFERENCES AND BIBLIOGRAPHY A Guide to the Reporting of Injuries, Regulations 2013 10. RELATED TRUST POLICY CRM002 Incident policy HSC001 Health and Safety Policy 10 of 15 Implementation Date: 06.05.2014

Appendix 1 - RIDDOR Investigation Report Template Claim/RIDDOR Reference: Datix Reference: Date of Incident: Incident Type: Staff involved: Overview of incident: Background: Risk assessments in place: Relevant policies and compliance: Findings of the review: Contributory Factors (including whether this was an avoidable incident) Root Causes Identified: Are there any safeguarding concerns: Lessons Learned: What actions are required: These need to reflect the list of Findings and what you believe are the learning points. Being open: Investigator Name: Job Title: Date: Signature 11 of 15 Implementation Date: 06.05.2014

ACTION PLAN: RIDDOR Ref. Incident Date. Name Lead Manager with responsibility for assurance on completion of action plan ACTION PLAN AGREED BY. DATE Root Level Level of By By Cause/Contributing Factor of Risk 11. AGREED ACTION Recommendation (Individual, Team, Whom When 11.1. Resources Required 11.2. Evidence of Completion 11.3. Sign Off Directorate, Organisation) 12 of 15 Implementation Date: 06.05.2014

WORKING PAPERS Information Gathering Claim file Incident Report Statements from staff involved and as witnesses Copies of Risk Assessments and Clinical Risk Assessments Any SSOW in place Training Records Equipment any guidelines for use or maintenance records Policies Trust and local Medical records Staff rotas Site photographs Timeline time/person grid Organisation and processes deficiencies Prior conditions basic causes (contributory factors) Unsafe acts active failures Failure to monitor/observe/act Incorrect decision or action Not seeking help when necessary How to identify the contributory factors and root causes: 5 whys technique Fishbone patient factors, task factors, individual task factors, social and team factors, education and training factors, equipment and resource factors, communication factors, working conditions factors, organisational and strategic factors Brainstorming / brainwriting Change analysis What does the policy say should happen What actually happened Is there a difference between the two Did the difference have any impact on the incident Deliberate Harm: Physical/Mental Health Test: Foresight Test: Substitution Test: Diseases and Dangerous Occurrences 13 of 15 Implementation Date: 30.04.2016

APPENDIX 2 NHFT EQUALITY ANALYSIS TOOL SEE OVER ARCHING H&S EQA 14 of 15 Implementation Date: 06.05.2014

Diseases and Dangerous Occurrences 15 of 15 Implementation Date: 30.04.2016