5 Key issues

5.1

In most cases a serious incident does not result from one single event, but is more likely to have involved cumulative triggers which, in isolation may have no effect, but when they occur in an event chain can be serious or even catastrophic.

5.2

When investigating a serious incident, it is important to concentrate on the facts, with a retrospective review of events to establish the underlying causes. Analysis will then identify areas for change, looking at long-term solutions, improving standards and improving patient safety and to minimise reoccurrence in the future or to reduce the level of harm.

5.3

The key features of a good investigation are:

• 5.3.1

  Clear terms of reference and parameters (scope);

• 5.3.2

  Involvement of staff involved, and patients and carers where possible;

• 5.3.3

  A thorough identification and analysis of events with clear rationale;

• 5.3.4

  A clear and concise report;

• 5.3.5

  SMART actions put in place to prevent repeat incidents.

5.4 Why investigations are necessary

• 5.4.1

  Serious Incidents can occur across KMPT and it is the responsibility of staff to ensure we learn from these, avoid repeating the same mistakes and introduce safer ways of working, better services to patients and ensure high standards of care are delivered across the organisation. In order to do this we need to be able to investigate the underlying root cause(s). The investigations do not look to apportion blame but instead looks reasons at why Serious Incidents occur.

• 5.4.2

  We achieve this by creating an environment of open and honest review of incidents. This enables staff at all levels to review practice and service delivery, learning lessons and enabling the development of safer systems of working, ensuring and supporting improving standards of care.

• 5.4.3

  It is important to also note that learning occurs equally from good practice as well as practice that requires improvement.

5.5 The Process for Effective Internal and External Communication

• 5.5.1

  KMPT executive team fully supports the expectation that staff participate in the investigation process as our opportunity to learn and develop improving standards and improving safety. Effective communication is necessary to ensure all those who have been involved in the serious incident fully understands:
  • a) The time scale;
  • b) Their involvement and what they can expect when being involved in the investigation if required; c) Any other role they are being asked to contribute such as a review of the process, a consultation group, or as lead clinicians to comment on an aspect of practice. Staff, patients or any other group may be approached by the Investigating team to take part in the investigating process, and their roles will be clearly stated. Communication back to those involved will be made explicit so all are aware when they can expect feedback and the final report.

• 5.5.2

  Following a decision made by the Trust Wide Patient Safety and Mortality Panel to investigate a Serious Incident, the Care Group Patient Safety Leads will identify an investigation team who will ensure all communication is undertaken, recorded and completed:
  • a) Contacting, communicating and meeting with patients, families/carers;
  • b) Ensuring staff are communicated with prior to any meeting to discuss their involvement. Support is given to staff who may be asked to contribute to the learning process;
  • c) That the investigation is completed within the national timescale and
  • d) And ensure feedback at the completion of the final report.

• 5.5.3

  On completion, the Lead Investigator / or Care Group Patient Safety Lead will ensure the report is shared with all relevant parties, for example:
  • a) Patient/families or carers
  • b) Service Manager and
  • c) Staff.

• 5.5.4

  Summaries of learning to share safety lessons and best practice will continue to be publicised in Trust Wide and local learning bulletins.

• 5.5.5

  If the need to communicate to all staff is urgent this will be done through the Communications Team.

• 5.5.6

  This will also be subject to the Duty of Candour Policy.

• 5.5.7

  The Serious Incident and Mortality Panel will identify when there is a need to involve external agencies following a Serious Incident. This is based on NHS England’s Serious Incident Framework 2015:
  • a) All homicides
  • b) All inpatient suicides
  • c) SIs that cross into other provider services
  • d) Death or serious injury through negligence
  • e) Death or serious injury of a member of staff
  • f) Equipment has significant failure causing serious injury or death
  • g) Serious Criminal act
  • h) Death in suspicious circumstances (unexplained/unexpected)
  • i) Involvement of other agencies requiring other expertise

• 5.5.8
  And will be reported, where necessary and appropriate, to

  • a) Clinical Commissioning Groups
  • b) NHS England/NHS Improvement
  • c) Health & Safety Executive
  • d) Local Authority Social Services
  • e) Acute Hospitals Trusts
  • f) Care Quality Commission
  • g) Medical Devices Agency
  • h) Medicines Regulatory Authority
  • i) Healthcare Products Regulatory Agency (MHRA)
  • j) Police
  • k) Environmental Health Agency (EHA)
  • l) Counter Fraud and Security Management Service

• 5.5.9 External reporting of incidents

5.6

Involving and supporting patients/carers/relatives and staff

• 5.6.1

  The Trust believes that patients and their families/carers are a critical part of learning from serious incidents. The level of patient/family/carer involvement depends on the nature of the incident, the patient and the patient’s consent for their family to be involved. Access to language and sign interpreters will be provided, as required.

• 5.6.2

  Usually the lead clinician will have commenced the Duty of Candour process as soon as is reasonably practicable (Regulation 20.2).

• 5.6.3

  Additionally, the identified lead investigator will
  • a) Make contact with all those involved and explain the process for the RCA
    learning review.
  • b) Arrangements should be made with the patient and/or their families/carers to meet with the investigation team to discuss potential areas for investigation and to be an integral part of the investigation process if they so wish. Unless there are specific indications to the contrary or the patient/their family requests other arrangements, a series of ongoing open discussions scoping the form of the investigation will take place between the staff providing the patient’s care and the patient and/or their relatives or carers.
  • c) Explain and agree how they can expect to be communicated with during the review.
  • d) Give an explanation of any timescales involved in the process.
  • e) Advise how to contact the investigating team.
  • f) Offer any other support the patient/family/carer would find beneficial that is reasonable.
  • g) Agree arrangements for sharing the final report.

• 5.6.4

  For further information on the Duty of Candour and the Trust process for ensuring full compliance please refer to the Duty of Candour – Being Open Policy.