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

4. Duties

4.1 KMPT Board

  • 4.1.1

    The KMPT Board is responsible for ensuring systems and processes are in place to undertake suitable and sufficient investigations so learning and implementation can be demonstrated. They will receive assurance from the Quality Committee through Summary and Exception reporting. They will demonstrate leadership in underpinning a learning and open culture by supporting staff in taking forward the Management and Investigation of Serious Incidents and Duty of Candour Policy, and by ensuring KMPT continues to demonstrate improvements in service delivery and safety.
  • 4.1.2

    It is KMPT Board’s responsibility to ensure staff feel safe to report issues and the information they share will be treated with respect and acted upon appropriately for the improvement of the safety and quality of KMPT services. They will support Just Culture.
  • 4.1.3

    The KMPT Board will ensure that there are systems and processes in place to evidence learning from Serious Incidents. They will support the PSIRF model when released.
  • 4.1.4

    Board members may be required to attend Immediate Management Reviews.

4.2 The Quality Committee

  • 4.2.1

    The Quality Committee, on behalf of the KMPT Board, will review the Quality Digest They will receive assurance that underpins that change has been/is being embedded throughout KMPT where it is appropriate to the learning. They will provide leadership and support to Care Group Heads of Service in undertaking their programme in continuous learning, review, implementing and sustaining change and then evaluating the outcomes.

4.3 The Trust Wide Patient Safety and Mortality Review Group

  • 4.3.1

    The Trust Wide Patient Safety and Mortality Review Group Chaired by the Chief Nurse is responsible for ensuring evidence is available to demonstrate that learning is taken forward across the Trust. Additionally, the Group will monitor exception reporting of delayed actions from SIs. . It will also review Trust-wide action plans developed from Serious Incidents except those reported direct to other groups such as the physical health action plan.
  • 4.3.2

    The group will ensure learning is disseminated across KMPT and actively support the continuous publication of best practice and examples of learning from Serious Incidents via the learning from experience group to ensure all staff have access to information and that there is a continuous re-evaluation of risk reduction measures undertaken in a systematic and sustained process.
  • 4.3.3

    The group will ensure that the organisation has adequate methods to ensure evidence of learning is captured.
  • 4.3.4

    The final completed action plan from homicide serious incidents will be reviewed and approved for closure at this meeting.

4.4 Trust Wide Serious Incident and Mortality Panel

  • 4.4.1

    The Trust Wide Serious Incident and Mortality panel is chaired by the Head of Patient Safety or their deputy and sits twice a week on Mondays and Wednesdays.
  • 4.4.2

    The purpose of the panel is to review all incidents reported on Datix where the level of harm is moderate to death and make decisions about the level of investigation required (see appendix 3), based on the 72 hour management report and further review where necessary, such as from experts or additional review by the corporate patient safety team. This may include a structured judgement review.
  • 4.4.3

    When it is unclear if a case is to be reported on STEIS, the Panel is to seek advice from Executive Directors.
  • 4.4.4

    Decisions will, be made in line with national guidance and KMPT decision making flow charts (appendix 4).
  • 4.4.5

    The Panel must identify a panel member to escalate to executive staff and to the communications team when cases are identified which are likely to attract publicity or have been/may be in social media, or which may require their consideration and escalation.
  • 4.4.6

    The Panel will agree responsibility (in conjunction with the executive lead if required) for informing the patient, family and/or carers if the case is likely to attract publicity through media forms.
  • 4.4.7

    The Panel will receive information from care groups about initial learning from all Serious Incidents to be reported on STEIS. When no initial learning has been identified, care group leads attending the Panel will be responsible for escalating to care group leads to ensure initial learning is put in place.
  • 4.4.8

    The Panel will devise terms of reference for root cause analysis investigations. Expert opinion must be sought if decisions on STEIS making cannot be made.

4.5 Expert Groups

  • 4.5.1

    Expert groups within the Trust, such as the Medication Review Group, and physical health group will routinely monitor the number and types of incidents arising from their specialty and ensure appropriate actions are taken and reported externally as required (see appendix 3).

4.6 Care Group Governance/Risk Management Groups/Care Group Leads

  • 4.6.1

    Care group leads are responsible for ensuring 48 hour reports are completed for any possible Serious Incident within 48 hours.
  • 4.6.2

    Care group patient safety leads are responsible for ensuring that 48 hour reports are completed to a good quality, are available for the Serious Incident and Mortality Panel and include information that enables the Panel to make a reasonable decision on whether to report on STEIS.
  • 4.6.3

    Care group leads must ensure initial learning is identified for STEIS reported cases, and implemented. The Care Groups will retain responsibility for implementing local action plans and ensuring there is a system of evaluation and evidence of learning. They will provide evidence on service changes and improvements and evidence of the implementation of best practice. They will review and monitor their Serious Incidents and ensure adequate SMART (specific, measurable, achievable, relevant and time-based) actions are put in place.
  • 4.6.4

    Care Group Groups will utilise the information gained from the analysis of reports and ensure risk management and risk reduction strategies are put in place. Escalation and dissemination of urgent issues should take place through care group processes.
  • 4.6.5

    Care Groups will be responsible for ensuring actions from Serious Incidents are completed within the given timeframe when related to their services.
  • 4.6.6

    The care group patient safety teams must review incidents on a daily basis to ensure any cases that require escalation to the Serious Incident and Mortality Panel are escalated in a timely manner.
  • 4.6.7

    The Care Group leads will sign off root cause investigations in line with appendix 8.
  • 4.6.8

    Care group patient safety leads and appropriate care group leads will attend Immediate Management Reviews, and be responsible for ensuring appropriate attendance at these meetings.
  • 4.6.9

    Care group leads will ensure staff participate in root cause analysis investigations.
  • 4.6.10

    Care group leads will ensure that Duty of Candour is completed within legal framework timeframes.
  • 4.6.11

    Care group leads will ensure support is provided to all staff involved in Serious Incidents, including staff that have been caring for the individual patients. This will include on-going support as well as initial support. This relates to all staff, including NHSP staff, agency staff, locums and students and any other staff involved including support staff.
  • 4.6.12

    Care group patient safety leads and care group leads will be responsible for ensuring appropriate attendance at the Serious Incident root cause analysis action plan meeting.

4.7 Chief Executive

  • 4.7.1

    The Chief Executive has overall responsibility for ensuring investigations are appropriate and effective and learning is identified and disseminated across the organisation. The Chief Executive is committed to KMPT demonstrating sustainable effective change based on learning from Serious Incidents.

4.8 Chief Nurse (Designated Board Member Lead for Patient Safety)

  • 4.8.1

    The Chief Nurse takes responsibility for ensuring all serious incidents are managed and investigated appropriately according to KMPT Policy and meet all external requirements. The Chief Nurse takes responsibility for sharing lessons learnt, ensures that the Chief Executive and Trust Board are appraised of incidents that are reportable to the Care Quality Commission, NHSE/I, Clinical Commissioning Groups and other external Stakeholders.
  • 4.8.2

    Ensures learning is demonstrable and evidenced and good practice is shared across the organisation.
  • 4.8.3

    Takes responsibility for alerting the Chief Executive of high-profile cases or those that risk organisational reputation.
  • 4.8.4

    The Chief Nurse will Chair, or appoint a deputy, for all Immediate Management Reviews (IMRs).

4.9 Head of Patient Safety

  • 4.9.1

    The Head of Patient Safety will Chair the Serious Incident and Mortality Panel or ensure a deputy is available.
  • 4.9.2

    The Head of Patient Safety will quality check all root cause analysis investigations as outlined in appendix 8 or ensure a deputy is appointed when not available.
  • 4.9.3

    The Head of Patient Safety is responsible for ensuring appropriate escalation of all Serious Incidents takes place and for appropriate escalation for any areas of particular concern such as homicide and reputational concerns.
  • 4.9.4

    The Head of Patient Safety will attend IMRs, be responsible for setting up meetings and ensure appropriate attendance from the corporate Patient Safety Team and ensure notes are taken and distributed within one working day of the meeting.
  • 4.9.5

    The Head of Patient Safety or Serious Incident and Complaints Investigation Lead is responsible for ensuring downgrade requests of Serious Incidents is appropriate.

4.10 Central Investigation Team (CIT)

  • 4.10.1

    The CIT will ensure all root cause analysis Serious Incident investigations are completed in line with national timeframes (see appendix 8).
  • 4.10.2

    The CIT will be responsible for seeking appropriate expert advice (internally or externally) for all root cause analysis Serious Incident investigations (except information governance investigations).
  • 4.10.3

    The CIT will ensure involvement of patients/families/carers in investigations throughout the investigation, and in line with Duty of Candour.
  • 4.10.4

    The CIT will lead and diarise the root cause analysis investigation action plan meetings in a timely manner.
  • 4.10.5

    The CIT will ensure cases are reported on STEIS in accordance with the Serious Incident framework.
  • 4.10.6

    The CIT will investigate in line with the Just Culture guide.
  • 4.10.7

    The CIT is expected to identify key staff involved and ensure that they are aware of the investigation process, reiterating that the investigation is a learning process.
  • 4.10.8

    The CIT lead investigator will share the findings, and usually the investigation report with the patient/family, except in exceptional circumstances such as at police request, where doing this may increase the risk to the patient (e.g. in some safeguarding or domestic violence cases).
  • 4.10.9

    All investigators of root cause analysis investigations must be trained in the process.

4.11 Patient Safety and Complaints Facilitator and Mortality Review Manager

  • 4.11.1

    The Patient Safety Facilitator and Mortality Review Manager are responsible for ensuring completion of 72 hour reports in line with appendix 9.

4.12 Role of Clinicians/Specialist Advisors

  • 4.12.1

    Clinicians and specialist advisors will provide expert opinion and support to the investigation process.
  • 4.12.2

    This will be determined at the onset of the investigation process by the Serious Incident and Mortality Panel. However, it is sometimes only recognised that expert involvement will be required as the investigation proceeds and experts may be included later in the investigation on occasions. CIT will identify this additional expertise.
  • 4.12.3

    Where there is insufficient expertise within the organisation, KMPT will consider identifying an external Consultant who will support the CIT.

4.13 Communication Team

  • 4.13.1

    Communications are a vital element of supporting and delivering effective management of serious incidents. The Trust ensures that robust communication and media management arrangements are in place for both internal and external communication. In some cases, serious incidents may lead to media attention which can be prolonged. The Trust will make every effort to ensure that staff are informed and supported prior to any media involvement (see corporate communication strategy).

4.14 All Staff

  • 4.14.1

    All staff have a responsibility to highlight and report any incidents or risk issues on Datix that would warrant further review or investigation.
  • 4.14.2

    KMPT will expect them to contribute fully to the investigation process in an open and honest manner.

4.15 Patient Safety Specialists

  • 4.15.1

    Patient Safety Specialists have been appointed by KMPT and they are responsible for attending update meetings from NHSE/I, developing the Patient Safety Strategy for KMPT and embedding this by April 2023, updating KMPT, and ensuring that investigation processes are embedded into KMPT.
  • 4.15.2

    They are also responsible for ensuring that adequate support is provided to the investigation process.
  • 4.15.3

    They are responsible for ensuring that staff are trained in line with the patient safety syllabus.

4.16 Initial Management Review (IMR) Panel

  • 4.16.1

    The Panel is required to determine actions for high profile cases, possible high-profile cases, homicides and child deaths. It will be led by the Chief Nurse or deputy and will follow the format in appendix 2.

  • 4.16.2

    Panel members are expected to prioritise attendance when requested and convened, or to appoint a deputy to attend.
  • 4.16.3

    The Panel will make decisions regarding immediate actions required and appropriate liaison and escalation as appropriate.
  • 4.16.4

    The IMR note taker will ensure notes of meetings are sent within one working day of the meeting to enable timely actions.