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 culture by supporting staff in taking forward the 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.

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 Executive Director of Nursing and Governance 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 SI's.
  • 4.3.2

    They 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.

4.4 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 the 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 and external reporting, based on the 72 hour management report and further review where required.
  • 4.4.3

    Decisions will, be made in line with national guidance and KMPT decision making flow charts (appendix 4 and 5). This may include further review before a decision is made or that a structured judgement review is required.
  • 4.4.4

    To identify 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.
  • 4.4.5

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

4.5 Trust Wide Health Safety and Risk Group (TWHSRG)

  • 4.5.1

    The TWHSRG will routinely monitor the number and types of incidents arising from health and safety issues, in particular those that are reportable under the RIDDOR regulations.
  • 4.5.2

    The TWHSRG may also review the numbers of clinical and non-clinical incidents to establish themes and trends and assist with obtaining assurances for the management of risk.

4.6 Care Group Governance/Risk Management Groups

  • 4.6.1

    The Care Groups will retain responsibility for implementing local action plans and ensuring there is a system of evaluation. 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 will organise any additional investigations.
  • 4.6.2

    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.

4.7 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 Executive Director of Nursing and Quality (Designated Board Member Lead for Patient Safety)

  • 4.8.1

    Takes responsibility for ensuring all serious incidents are managed and investigated appropriately according to KMPT Policy and meet all external requirements. The Executive Director of Nursing and Quality takes responsibility for sharing lessons learnt, ensures that the Chief Executive and Trust Board are appraised of incidents that are reportable to the 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.

4.9 Lead Investigating Manager/Team

  • 4.9.1

    The lead investigator will have received training in RCA investigating either through specific training or through experience. The lead investigator should be 2 day RCA trained. Reviews will be conducted using RCA methodologies.
  • 4.9.2

    Other members of the investigating team may be trained in RCA but may also be part of the investigating team. This could include, for example, pharmacy, expert nurses, doctors, corporate staff, health and safety or security staff due to their expertise.

4.10 Role of Clinicians/Specialist Advisors

  • 4.10.1

    There will be access to staff that are able to provide consultation and support to the process.
  • 4.10.2

    This will be determined at the onset of the investigation process. Specific support will be allocated to each team. 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.
  • 4.10.3

    Where there is insufficient expertise within the organisation KMPT will consider identifying an external Consultant experienced in RCA who will support the Team.

4.11 Communication Team

  • 4.11.1

    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).

4.12 All Staff

  • 4.12.1

    All staff have a responsibility to highlight and report any incidents or risk issues on Datix that would warrant further review or investigation.
  • 4.12.2

    KMPT will expect them to contribute fully to the investigation process openly and honestly


  • 4.12.3 

    The Chief Operating Officer and Medical Director will sign off high profile cases as well as the Director of Nursing and Quality, Heads of Service, Patient Safety Lead and Head of Patient Safety.