incident reporting investigation policy · nwas incident reporting & investigation policy page:...

INCIDENT REPORTING &

INVESTIGATION POLICY

NWAS Incident Reporting & Investigation Policy Page: 2 of 23

Author: Head of Risk and Safety Version: 5.0

Date of Approval: September 2012 Status: Final

Date of Issue: October 2012 Date of review: October 2014

Recommending Committee: Quality Committee Approving Committee: Trust Board Approval Date: September 2012 Version Number: 5.0 Date of Development: February - August 2012 Date of Issue: October 2012 Review Date: October 2014 Responsible Executive Director: Director of Performance and Patient Experience Responsible Manager: Assistant Director, Healthcare Governance Competent Manager(s): NWAS Head of Clinical Safety

NWAS Head of Risk and Safety For use by: All Trust staff





CHANGE RECORD

Version Date of Change Date of release Changed by Reason for change

x 2.0 26th September

2007 1st October 2007 N Barnes Trust Board Approved

x 2.1 April 2008 July 2008 D Bullock Document Creation –

reviewed from approved document Sept 07

x 2.2 July 2008 August 2008 D Bullock Revised draft following

consultation

x 2.3 5th August 2008 2nd September

2008 F Buckley D Bullock

Amalgamated with Serious Untoward Incident Policy

x 2.4 8th September 2008 15th September

2008 N Barnes Submitted to EMT

x 3.0 19th September

2008 1st October 2008 N Barnes Trust Board Approval

X 3.1 17th February 2010 17th February 2010 F Buckley D Bullock

Review process commenced with Health and Safety Sub

Committee consultation

X 3.2 8th July 2010 October 2010 F Buckley D Bullock

Reviewed for submission to the Risk Management Sub

Committee

X4.0 October 2010 October 2010 F Buckley D Bullock

Approval to the EMT and Board of Directors

X4.1 15th February 2012 F Buckley

Review consultation process commenced with Health and Safety Management Group

X4.1 15th May 2012 F Buckley

F Rose

Reviewed in light of consultation comments and

NHSLA recommendations

X5.0

5th September 2012

F Buckley N Barnes

Presented and approved by Quality Committee





CONTENTS

Page

1.0 Introduction 5

2.0 Purpose & Scope 5

3.0 Aims & Objectives 5

4.0 Responsibilities 6

5.0 Related Trust Policies 13

6.0 Fair Blame Culture 13

7.0 Discrimination and Support 14

8.0 Whistle-blowing 15

9.0 Definitions 15

10.0 Incident Reporting Process 16

11.0 Incident Investigation 16

12.0 Grading of Incidents 16

13.0 RIDDOR reporting 17

14.0 Investigation Action Plans 18

15.0 Serious Untoward Incidents 19

16.0 External Incidents – Clinical and Non Clinical 19

17.0 Externally Lead Investigations 20

18.0 Health and Safety Representatives 20

19.0 Record Keeping 21

20.0 Education, Training and Development 21

21.0 Communications 21

22.0 Media Enquiries 22

23.0 NHS Constitution 22

24.0 Monitoring and Review of Policy 23

Appendix 1 - Terms of Reference: Incident Learning Forum

Appendix 2 - Incident Reporting Flowchart

Appendix 3 - Incident Report Form

Appendix 4 - Guidance and Terms of Reference for Investigation

Appendix 5 - NPSA Decision Tree

Appendix 6 – Trust Risk Management Matrix

Appendix 7 – Serious Untoward Incidents and StEIS reporting procedure

Appendix 8 – External Incidents (Inwards) Flowchart

Appendix 9 – Equality Impact Assessment





1.0 Introduction It is the policy of the North West Ambulance Service NHS Trust (NWAS, from herein referred to as the Trust) to learn from incidents in such a way as to reduce the likelihood and consequences of incidents occurring to as low a level as is reasonably practicable. In an effort to achieve this aim all incidents (both clinical and non-clinical) should be reported promptly, investigated as appropriate and all necessary remedial action taken. It is recognised that it is not possible to prevent all untoward incidents; however the Trust will learn from all incidents to ensure that reasonably practicable measures can be implemented to prevent recurrence. The Trust is committed to complying with its statutory responsibilities to ensure, so far as reasonably practicable, the health, safety and welfare of any patient in our care, our employees, service users and any other person who could be affected by the activities of the Trust. This policy aims to make sure that the Trust can meet its statutory obligations to report incidents, when required, to the appropriate external agency and to work with those agencies throughout the investigation process. The Trust will be open throughout the investigation with any incident, will report accordingly and provide feedback, where considered necessary or requested, to individuals involved, their carers, next of kin, other relatives or to relevant agencies.

The principles of this policy can be applied to the investigation of complaints and claims as well as incidents as well as identifying good practice and generating learning outcomes to reduce reoccurrence.

2.0 Purpose & Scope This policy applies to all employees of the Trust whilst undertaking Trust’s activities. 3.0 Aims and Objectives

To minimise injury to all, by ensuring that any lessons learned from any incident, near miss, disease or dangerous occurrence are acted on so that similar recurrence is avoided or eliminated in so far as is reasonably practicable.

To ensure that external agencies (e.g. Health and Safety Executive, NHS Litigation Authority, National Patient Safety Agency, Medicine and Healthcare products Regulatory Agency (MHRA) and NHS Protect) are informed in a proper and prompt manner.

To ensure the Trust complies with current legislation and external national standards e.g. NHSLA, CQC.





To inform the Trust’s Risk Registers where necessary with information regarding risks facing the Trust and its employees / patients etc so that these can be appropriately assessed, controlled and managed.

To facilitate learning from incidents and near misses, and ensure that such informs safe working practices, policies, procedures and training.

To improve the range of data for the purpose of trend analysis, and ensure that adverse trends are appropriately investigated and remedial action taken where necessary.

To provide information, instruction and training to the workforce in order that staff are aware of their duties and responsibilities under current regulations.

4.0 Responsibilities

Trust Board

Trust Board of Directors The Trust Board of Directors has the responsibility and accountability for the ownership of incident reporting and investigation via the approval of this policy and making resources available to mitigate identified risks. The Trust Board of Directors will receive assurance via the Quality Committee of aggregated incident reporting and investigation activity at least annually and by exception. Serious Untoward Incidents shall be reported via summary reports to Board of Directors meetings as required A member of the Trust Board will Chair the Incident Learning Forum. Chief Executive

The Chief Executive has overall statutory responsibility for having effective incident reporting and investigation systems in place within the Trust and for meeting all statutory internal and external reporting requirements. The Chief Executive will delegate this responsibility to the Director of Performance and Patient Experience.





Executive Management Team The Executive Management Team will receive and approve reports on Serious Untoward Incidents that have been reported through the Strategic Electronic Information System (StEIS) at least eight times a year. Health and Safety Management Group

The Health and Safety Management Group will receive and approve, for submission to the Quality Committee, non-clinical incident trend analysis together with any recommendations regarding corrective actions and required changes to policy and / or procedure to minimise re-occurrence. Clinical Governance Management Group

The Clinical Governance Management Group will receive and approve, for submission to the Quality Committee, clinical incident trend analysis and external incidents together with any recommendations regarding corrective actions and required changes to policy and or procedure

It will receive and approve clinical incident investigation summaries, and ensure that action is taken in order to minimise re-occurrence.

Trust Incident Learning Forum

The Trust Incident Learning Forum will receive and review analysis reports of complaints, concerns, claims and adverse events both clinical and non-clinical and external incidents. The Terms of Reference are included in Appendix 1. The Trust Forum will make recommendations for inclusion of identified risks onto the appropriate risk register(s). The Trust Forum will review the outcomes of investigations to ensure that organisational learning from incidents has taken place and where appropriate will recommend the relevant manager to share lessons with external stakeholders Performance and Patient Experience Senior Management Team It is the responsibility of the Performance and Patient Experience Senior Management Team:

To support the implementation of this policy across the Trust





To support the investigation of incidents, receiving reports and making recommendations to improve patient care.

To support the investigation of confidential enquiries, external reports, and any

subsequent action plans

Director of Performance and Patient Experience

It is the responsibility of the Director of Performance and Patient Experience:

To take ownership of the policy on behalf of the Chief Executive

To ensure that any changes in legislation or national guidance relating to incident

reporting and investigation are made known to the Executive Management Team and the Trust Board via the Quality Committee

To promote an open and fair culture within the Trust.

To oversee all serious untoward incident reports and investigations

As the Executive Lead for the Trust approve when incidents are reported through the

StEIS system and provide regular updates to the Executive Management Team. Executive Directors

It is the responsibility of Executive Directors

To ensure that all incidents, involving their directorate staff are investigated and reported upon, in line with this policy.

To ensure compliance with this policy within their area of control.

To monitor all relevant incidents ensuring that any recommendations regarding corrective actions are implemented locally.

Assistant Director, Healthcare Governance

It is the responsibility for the Assistant Director

To take the lead on compiling and reviewing the Trust’s Incident Reporting and Investigation Policy in line with legislation and national guidance.





To take a lead role in the Trust Incident Learning Forum.

Provide professional advice and guidance to all levels of the Trust management with regard to incident investigations and ensure that learning takes place.

To oversee root cause analysis investigations and ensure the findings are reported to the appropriate Committee of the Trust

Monitoring the effectiveness of implementing the policy

Head of Clinical Governance, Head of Clinical Safety and Head of Risk and Safety

It is the responsibility of these Heads to

To contribute to compiling, reviewing and ensuring implementation of the Trust’s Incident Reporting and Investigation Policy.

To ensure that appropriate reporting systems are in place in order to comply with all

duties in relation to the Incident Reporting and Investigation Policy.

To provide professional advice and guidance to all levels of the Trust management with regard to incident investigations and ensure that learning takes place.

To take responsibility for incident reporting and trend analysis to the Board of Directors /

Executive Management Team and relevant management groups, as directed

Health, Safety and Security Manager

It is the responsibility of the Health, Safety and Security Manager

To monitor and collate Trust wide statistics on all non clinical incidents that have been reported and investigated both internally and externally.

To provide assistance with management investigations including, where appropriate root cause analysis investigations and the provision of specialist advice to managers.

To ensure that relevant risks are highlighted onto the appropriate risk registers.

Provide support to the Health and Safety Practitioners and Safety and Security Practitioners in ensuring that all investigations are complete





Risk Manager

It is the responsibility of the Risk Manager

To report all StEIS incidents and forward investigation reports and recommendations to Lead PCT within agreed timescales

Work with local managers to ensure that all StEIS investigations are thoroughly

completed in a timely manner

To monitor and collate Trust wide statistics on all Serious Untoward Incidents that have been reported and investigated both internally and externally and report to the Assistant Director, Healthcare Governance.

Making Experiences Count Manager It is the responsibility of the Making Experiences Count Manager

To monitor high level clinical incidents ensuring they have been reported and investigated both internally and externally.

To provide specialist clinical advice and support to managers who are completing

investigations.

To assist, when required in the completion of root cause analysis investigations.

To ensure that relevant risks are highlighted onto the appropriate risk registers, as necessary

Clinical Governance Co-ordinator

It is the responsibility of the Clinical Governance Co-ordinator

To monitor all medicine management clinical incidents, their investigations, learning outcomes and recommendations.

To provide where required specialist clinical advice and support to managers in relation

to incident investigation.

Report medicine management incidents and investigations and to identify learning outcomes for recommendation to the Clinical Governance Management Group





Health & Safety Practitioner(s)

It is the responsibility of the Health & Safety Practitioner(s)

To receive and action accordingly non clinical incidents reported on Trust Incident Report Forms.

To ensure the reporting of RIDDOR incidents to the Health and Safety Executive.

To ensure that the correct management investigation of appropriate incidents is

undertaken.

To work with local managers and staff to minimise reoccurrence

To ensure that existing risk assessments are reviewed as a result of any incident or changes in practices and amended as appropriate.

Safety & Security Practitioner(s)

It is the responsibility of the Safety & Security Practitioner(s)

To provide specialist advice, guidance and support to managers who are completing investigations into either violence or aggression or fire safety incidents.

To ensure the NHS Security Management Service are informed of relevant incidents


All Managers It is the responsibility of all managers

To ensure that investigations are complete and where necessary immediate remedial action is taken

To ensure this policy and associated procedures are implemented within their areas of

responsibility.

To ensure that all staff and visitors, within their areas of responsibility, are aware of this policy, procedures for reporting, recording and investigation of incidents as necessary.





To ensure all staff, bank staff, agency workers and contractors under their control understand and follow this procedure accordingly.

Where no risk assessment exists for significant hazards, ensure that one is conducted in

conjunction with the Risk and Safety team to identify all significant hazards, so that risks can be reduced to an acceptable level. The results of those risk assessments must be communicated to all those who may be at risk.

When investigating:-

To grade all incident reports received using the Trust risk matrix.

To ensure that an Incident Report Form has been completed and forwarded for action in

accordance with Appendix 2. This should include the obtaining of witness statements if required.

To ensure that reporting incident timescales are adhered to as per this policy.

To review received Incident Report Forms and take any appropriate remedial action.

Once fully completed, ensure that the form is sent to the Risk and Safety Team within at least 7 working days of being made aware of the incident.

Investigations Officers

It is the responsibility of the Investigations Officer(s) to:

To inform where necessary the Head of Risk and Safety / Risk Manager of high level

incidents arising out of complaints / concerns that may require internal reporting (e.g. MHRA / NPSA / StEIS reportable incidents)

The responsibilities listed below relate specifically to External Incidents graded at either a level 4 or 5 on the Trust Risk Management Matrix. The investigation of complaints and concerns is as per those policies and procedures.

To ensure that the correct management investigation of appropriate incidents is

undertaken.


To provide specialist advice and support to managers who are completing investigations.

To assist, when required in the completion of root cause analysis investigations.





To ensure that relevant risks are highlighted onto the appropriate risk registers

All Employees:

It is the responsibility of employees:

To ensure that an Incident Report Form is completed (either by themselves or if incapacitated, by a nominee – e.g. colleague) as soon as practicable following an adverse incident or near miss. This form must be forwarded to their line manager for further investigation (Appendix 2)

To ensure that the Incident Report Form has all relevant fields completed to the best of

their knowledge (Appendix 3) 5.0 Related Trust Policies The Trust has various policies and procedures that support this policy some of which have specific actions which should be undertaken following a certain type of incident. The following is a list of some of these policies and procedures:

Being Open Policy Medicine Management Policy

Claims Policy Risk Management Policy

Complaints and Concerns Policy and Procedures Safeguarding Children Policy

Health & Safety Policy Safeguarding Adults Policy

Incident Learning Policy Whistle Blowing Policy

Infection Prevention and Control Policy & Procedures 6.0 Fair Blame Culture All employees have a major role to play in identifying and minimising inherent risks - both clinical and non-clinical. This can only be achieved if there is a progressive, honest and open work environment, where ‘near misses’ and incidents are identified quickly and acted upon appropriately, in a constructive way, without unnecessary recourse to disciplinary procedures. Staff who promptly and openly report an event or ‘near miss’ that may indicate a mistake or error of judgement on their part will be viewed more positively than if they do not. In the event of medical negligence litigation against the Trust, the Trust acts on behalf of any staff involved and will therefore be reliant on their cooperation. By reporting incidents promptly all the necessary facts and details can be obtained whilst still fresh in peoples’ minds and before relevant documentation or equipment becomes destroyed or unidentifiable. It may also be





possible to take steps to prevent a complaint or legal action being pursued in the first place. Further information can be obtained from the Legal Services Department as required. It is vitally important therefore that all employees adhere to the reporting procedures in place and that staff and management use the information together in a positive manner. 7.0 Discrimination and Support The Trust operates within an ‘Open and Fair Blame Culture’ that encourages and welcomes incidents to be reported, so that lessons can be learnt and any necessary action taken to prevent a recurrence. The Trust actively encourages staff to speak openly and freely and will reassure staff that whatever they say will be treated with appropriate confidence and sensitivity. The management of incidents will follow, where possible and appropriate, the principles of the Being Open (as per the Being Open policy) Staff will not be discriminated against, and should not be made to feel threatened by the process, or unjustifiably fearful of the outcome, as a result of having reported an incident. If the Trust identifies any areas where discrimination has occurred against a staff member who has reported an incident, then appropriate action, using existing Trust polices and procedures will take place. As part of the Trust’s policy of openness; support will be given throughout any investigation process, including open access by the staff to the Clinical Governance Managers / Risk Manager / Health Safety and Security Manager as necessary and if the investigation is protracted, regular updates to keep the staff informed. Support Mechanisms The Trust recognises that involvement in any incident can be stressful and has implemented a series of support mechanisms:

Risk and Safety / Making Experience Count Team

Local Manager support available at all times

Duty Control Manager/Duty Manager

Occupational Health and/or confidential counselling services





These services can be accessed at anytime and are often offered to staff proactively in the event of an involvement of certain types of work related incidents. Guidance can be sought from the local management team and / or Human Resources Department. 8.0 Whistle-blowing The Trust operates a Whistle Blowing Policy in accordance with the Public Interest Disclosure Act 1998. This enables individuals to report issues which concern them which are outside of the incident reporting system. Please refer to the Whistle-Blowing Policy or consult Human Resources Department for further guidance and information. The principle of whistle-blowing within the NHS is for staff to be able to raise genuine concerns without the fear of any form of retribution, victimisation or detriment. Any concern will be treated seriously in accordance with the Trust’s policy. Any requests for privacy will be respected and disclosures will only be made with the individual’s express knowledge. 9.0 Definitions An adverse event is one where in the course of the Trust’s harm (actual or potential) is realised. This includes staff, patients, non employees, Trust premises or property or the environment, patient safety, clinical incident.

Adverse event – where an incident results in actual harm, loss or damage.

Near miss – where an incident did not result in actual harm, loss or damage.

Hazard – something with the potential to cause harm.

Risk – likelihood that harm will be realised.

Serious Untoward Incident – Where an incident results in is an unforeseen event whether or not caused by the act or omissions of staff, which results in permanent harm or death of a patient, visitor, member of staff or any other person directly or indirectly affected by the Trust’s activities.

All of these must result in the completion of an Incident Report Form (Appendix 3). Full guidance on the completion of the Incident Report Form can be found in the Health, Safety and Security A-Z toolkit.





10.0 Incident Reporting Process All incidents and near misses must be reported using the Trust Incident Report Form. Guidance on the completion of the form is available in the Health, Safety and Security A-Z toolkit. The exception to this is safeguarding incidents which must be reported immediately by phone to the Support Centre Reporting procedure is detailed in Appendix 2.

11.0 Incident Investigation Investigations are initially led by the line manager or Advanced Paramedic for the member of staff. Owing to the type of incident involved they are capable of being dealt with quickly and corrective action implemented to prevent recurrence. It is recognised however that there may be occasions where the line manager may not be able to immediately attend to the incident or start the investigation. In these instances, local managers will be asked to support the reporting and investigation process. Assistance can be obtained from specialist managers within the Trust to support the investigation if required. Guidance on conducting investigations can be found as Appendix 4 to this policy. In the event that the Risk and Safety Team feel that following the investigation further action is required by a senior manager they will make contact and request further investigation and action and for reports to be provided accordingly. The decision to request further investigation will be based on the risk assessment score of the incident. Some incidents may require the formation of an incident review panel following the more detailed investigation/ root cause analysis. The panel may use the NPSA decision tree as a tool to assist them in their recommendations, please see details in Appendix 5. 12.0 Grading of Incidents All incidents should be graded using the Trust’s Risk Matrix as soon as possible after the incident which will inform the appropriate level of investigation (please refer to Appendix 6) They should be assessed and quantified using the consequence criteria only making all incidents graded on a 1-5 scale (5 is the most serious). The likelihood score will only be used when completing risk assessments or entries on the risk register.





The severity of the score will determine the level of investigation and sign off. Initial and Subsequent Grading Scores Incident Reports will be given an initial risk score and documented on the Incident Report Form this will be undertaken by the local manager conducting the initial investigation as soon as possible after the incident. Following submission of the Incident Report Form to the Risk and Safety Team the risk score will be reviewed and changed if required by the relevant Manager / Practitioner. The Risk and Safety Team will decide if the incident requires further investigation either by a specialist manager within the Trust, external expertise or senior management within the Trust. The decision will be based on guidance from the Trust’s Risk Matrix. Risk Identification through Incidents Incidents that are resolved by appropriate investigation and action taken are classed as controlled risks and do not require any further action. Trend analysis of incidents, complaints and claims may also be identified through the production of reports from DATIX system. These trends will be addressed by risk assessment and grading and the appropriate Risk Registers updated accordingly. Risk Treatment Plans will be produced to ensure that these risks are dealt with by reducing or controlling the likelihood and consequence of the occurrence of the incidents. 13.0 RIDDOR reporting To comply with the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (4th edition 2012), the Trust must notify the Health and Safety Executive of certain types of incidents within the prescribed time limits. RIDDOR reporting is the responsibility of the Risk and Safety Team. The following RIDDOR reportable serious incidents must be reported to Risk and Safety as soon as possible

Work related injury or illness that has resulted in hospital admission (for more than 24 hours) or absence from work for more than 7 days

Fatal incidents

Major Injury – examples include





o All fractures – except fingers / thumbs / toes o Amputations o Dislocations of shoulder / hips / knee / spine o Where there is a loss of consciousness or resuscitation needed

This is during the course of our duty to the patient and not what we have been asked to attend.

Dangerous Occurrences

Certain work related diseases 14.0 Investigation Action Plans At the end of the investigation process, completed documentation is retained on the DATIX system. Local actions to prevent or reduce the risk of recurrence should be undertaken immediately or as soon as reasonably practicable confirmation of this should be documented on the Incident Report Form. Further investigations or root cause analysis should be presented along with an action plan for implementation of the recommendations to the appropriate Management Group / team of the Trust. This should be minuted and followed up at subsequent meetings to ensure that the action has been taken or lesson learned to provide assurance that the risks to the Trust have been managed and reduced to the lowest practicable level, e.g.

Appropriate Health and Safety Business Group

Directorate Senior Management Team

Incident Learning Forum

Appropriate Committee / Management Group

Executive Management Team/ Board of Directors





15.0 Serious Untoward Incidents / StEIS reports A serious untoward incident is an unforeseen event whether or not caused by the act or omissions of staff, which results in permanent harm or death of a patient, visitor, member of staff or any other person directly or indirectly affected by the Trust’s activities. This would also include “rogue” staff and events which affect multiple patients i.e. “rogue” staff or infected worker(s). Examples of serious untoward incidents (SUIs) are:

The accidental death of, or serious injury to, a patient during treatment / whilst in our care, or to a member of staff or other person on or off Trust premises or vehicles.

Failure of procedures so serious as to endanger life

Death or injury where foul play by a member of staff is suspected

Any event which could affect multiple patients (not including major operational incidents) e.g. ‘rogue staff’, infected worker

Serious damage to premises of the Trust e.g. fire, collapse

Any incident which involves Trust staff or patients which is likely to produce significant legal, media or other interest which, if not properly managed, may result in a significant detrimental effect on the Trust’s reputation or resources

Please note that this list is not exhaustive.

Where the Strategic Health Authority and/or Regional Director of Public Health need to be informed, this will be done via the Strategic Executive Information System (StEIS). The Director of Performance and Patient Experience, with support from the Medical Director is responsible for determining which matters are referred StEIS and the Risk Manager is responsible for updating the StEIS database. Serious Untoward Incidents and StEIS reporting process is detailed in Appendix 7. 16.0 External Incidents – Clinical and Non Clinical Frequently external Trusts and other organisations i.e. Acute Hospitals, Primary Care Trusts and General Practitioners contact the Trust to raise their concerns over a specific incident or event. This ranges from concerns over inappropriate clinical care to delays in patients receiving treatment. These incidents must be investigated and responded to with equal importance as internal incidents. External Incident reporting process is detailed in Appendix 8.





17.0 Externally Lead Investigations There are occasions where the investigation will be lead and conducted by an external agency e.g.:

Police – where the incident may be as a result of a criminal act

HSE – where the incident is reportable under the RIDDOR Regulations and they commence an investigation into the circumstances of the event

NHS Litigation Authority – where a claim has been made against the Trust under the clinical negligence, employer’s liability or public liability schemes

Counter Fraud and Security Management Service (CFSMS) – where there is a suspicion of fraud

Owing to the sensitive nature of an incident or as part of the commitment of the Trust to ensure that incidents are investigated in an open and fair culture the lead responsibility to investigate may be passed to another external agency. The decision to refer to an external agency will be the responsibility of the Chief Executive in consultation with the Executive Directors of the Trust. 18.0 Health & Safety Representatives In accordance with the Safety Representatives and Safety Committee Regulations (SRSC) 1977 and the Health & Safety (Consultation with Employees) Regulations 1996 a recognised Health & Safety Representative will be notified of a major injury incident. Where appropriate they may be included as a panel member during a Root Cause Analysis investigation (RCA) – there are certain exemptions to this requirement as identified in the SRSC Regulations. Those H&S Representatives who undertake RCA investigations should be able to demonstrate that their level of training is of an equivalent standard to the National Patient Safety Agency’s Root Cause Analysis. It is also recognised that H&S Representatives have a right to investigate incidents however wherever possible the Trust will seek to conduct a joint investigation into an incident with the agreement of the staff member.





19.0 Record Keeping

All Incident Report Forms are completed recording only facts and not opinions or assumptions. Immediate corrective actions and the investigations outcomes are also recorded by the Investigating Manager. Copies of statements, photos etc must be retained with the Incident Report Form.

Copies of all forms will be treated as confidential and securely retained by the relevant departments, e.g. Occupational Health, Risk and Safety Team.

Information on the forms will be entered onto DATIX database by the Datix Administrators

All such information will be kept in accordance with the Data Protection Act, Caldicott Report and any other information security arrangements applied within the Trust.

Individuals and their appointed representatives have the right to see any records relating to them, however appointed representatives must have a signed authority.

Information given to any member of staff, staff representative, patient or patient representative (next of kin or carer) must be recorded and this must be retained on Datix. It is not necessary to seek explicit consent to disclose relevant information in the ongoing provision of healthcare, however consent should be obtained if patient information is required to be passed to external agencies outside of the NHS i.e. Police

20.0 Education, Training and Development Staff will be trained in accordance with the schedule contained in the Risk Management Training Procedure with particular reference to the Training Needs Analysis. 21.0 Communications Communication is an extremely important element of the investigation and learning phases associated with any incident. The Trust will provide a copy of this policy on the Trust’s intranet and internet sites, and on all stations as part of the Health, Safety and Security A-Z toolkit. Where an incident is reported on an Incident Report Form the individual making the report will be provided with feedback on the outcome of the investigation by their line manager, who will complete the managers report section of the Incident Report Form. Additionally, the results of appropriate investigations will also be notified to appropriate Forums and Business Groups and to the appropriate Management Group / Committee of the Trust.





Where action or learning has involved a change in working practices, as recommended by the Trust Incident Learning Forum, this will be communicated through all appropriate channels to Trust employees e.g. revised risk assessments, safety notices, training memos, training, updated policy/procedures, newsletters, Trust intranet, etc. The Trust is keen to share any lessons learned with appropriate external stakeholders. The Trust will ensure that before any report is made public or provided to the media or other organisation; all persons involved or connected with the incident will be consulted first and be afforded the opportunity to read any investigation report. Any information provided will be documented by the Trust. Persons may be included are:

Members or staff

Next of kin of staff (in the event of a major or fatal incident)

The patient involved in an incident

The patient’s next of kin or carer(s)

Relevant Medical or Healthcare professionals (e.g. General Practitioner) It is important to note however that the sharing of lessons learned by the Trust does not necessarily require divulging all incident details; it may be that the Trust decides to share good practice recommendations and learning solutions that have been developed following the incident. 22.0 Media Enquiries No employee of NWAS NHS Trust is authorized to make any comment to any media agency without the express permission of the Trust. Please refer to the Communication and Engagement Strategy available on both the intranet and internet. 23.0 NHS Constitution The NHS Constitution establishes the principles and values of the NHS. It includes staff pledges, which state what the NHS expects from its staff and what staff can expect from the NHS. We view this as part of our commitment to being a good employer, making our staff feeling valued. NWAS will ensure that all engagement activities comply with the underlying principles of the Constitution.





24.0 Monitoring of the Policy The NWAS Incident Reporting and Investigation Policy will be reviewed every two years, however, should national guidance or legislation change then the policy may be reviewed earlier.

Area for Monitoring Monitoring Process

Duties Monitored through the KSF process for individual and through the Terms of Reference review for the identified groups

Process for reporting all incidents/near misses, involving staff, patients and others

Completion of an annual audit of 1% of all IRFs presented to the Health and Safety Management Group and Clinical Governance Management Group by the Head of Risk and Safety

Process for reporting to external agencies


Organisation’s expectation in relation to staff training as identified in the training needs analysis

In line with the Risk Management Training Procedure

Different levels of investigation appropriate to the severity of the event


Process for involving and communicating with internal and external stakeholders to share safety lessons

Annual report to the TIFL and included on the lessons learnt database

Process for following up relevant action plans


Reporting Process

The Heads of Clinical Safety and Risk and Safety will be responsible for ensuring:

The relevant Management Group receive reports on the reporting and investigation of both clinical and non clinical incidents.

The Trust Incident Learning Forum will also monitor clinical and non clinical incidents to identify learning points for the Trust.

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