Management of investigations and serious incidents policy

The purpose of this policy is to ensure that risks associated with serious incidents are identified and managed in accordance with best practice and in line with the expectations of the NHS Resolution, the Health and Safety Executive, the Care Quality Commission, NHS England and NHS Improvement, Clinical Commissioning Groups and the public.

Publication date:
01 September 2019
Date range:
September 2019 - September 2022

14. Monitoring compliance with and effectiveness of this document

Monitoring compliance and effectiveness of this document
What will be monitored How will it be monitored Who will monitor Frequency Evidence to demonstrate
Action to be taken in the
event of non-compliance
Completeness of information
on 72 hour management
reports as reported via the
Datix system
Patient Safety and Risk
Manager will review the 72
hour reports to ensure
Trust Wide Serious Incident
and Mortality Panel.
All forms on receipt Trends will be raised
with The Head of
patient Safety.
The managers of Datix 72 hour
report will be contacted by the
patient safety and risk manager
in the first instance and
thereafter using the escalation
process to Head of Service
Reporting to The Quality
Via reporting schedule for
key committee/groups
Directorate meetings
Heads of service
Medical Director
Director of Nursing and Quality
Monthly Reports
Minutes of meetings
Director of Nursing and Quality
Demonstration of learning
from incidents and evidence
of change
Through Clinical Audit and
Effectiveness Team
Learning from experience
Director of Nursing and Quality
Care Group Patient Safety and
Risk manager.
Care Group
Governance meetings
QPR Learning from
experience group
Minutes of meetings
Reports re-audit/reevaluation
Follow up with Care group Heads
of service risks highlighted
Reporting within the
timescales for Serious
Trust Wide Patient Safety
and Mortality review group
Deputy director of Quality and
Monthly Board
Minutes of meetings
and reports
Care Group Leads on the panel
will take action through the Care
Groups to ensure compliance
Staff are aware of how to
raise concerns
Concerns recorded in Datix
incident forms.
Locality managers Ongoing/Monthly


There are no exceptions to this policy.