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

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

- Incident Type Contact (who and how)
NHS England
Clinical
Commissioners
Groups
Local Authorities
e.g. Social
Services, police

Suicide of any person on NHS premises or
under the care of a specialist team in the
community.

Homicide committed by a patient with
mental health problems.

Serious injury or unexpected death
involving a member of staff, visitor,
contractor or another person to whom the
organisation owes a duty of care
Serious damage to NHS property,
particularly resulting in injury or disruption
of services e.g. through fire, flood or
criminal activity.

Incidents associated with infection that
produce, or have the potential to produce,
unwanted effects involving the safety of
patients, staff or others.

Any other Serious Incidents that may be
identified as a cluster of events that lead to
something more significant including those
that may attract media attention.

The Serious Incident and Mortality
Panel review the management
review and Rio where necessary to
identify if a Serious Incident has
occurred. Where it is decided that
this is the case, the Serious Incident
Administrator will enter the incident
on to the STEIS System within two
working days.

Other organisations should be
notified as soon as possible to
ensure appropriate engagement.
Communication leads will be
determined through the above
panel.

National Reporting & Learning
System by the Datix Team within
two working days.

Her Majesty’s
Coroner

Deaths to be reported to HM Coroner:

  • Death where no doctor saw the
    deceased during his or her last illness;
  • A death where, although a doctor
    attended the deceased during the last
    illness, the doctor is not able or
    available, for any reason, to certify the
    death;
  • Death from industrial diseases or
    poisoning
  • Death at work
  • Cot death and postnatal deaths
  • the death was sudden and unexplained;
  • Death occurred during an operation or
    before full recovery from anaesthetic
  • Cause of death unknown or within 24
    hours of admission
  • Any violent, suspicious or unnatural
    death or a death due to neglect
  • Drug related deaths
  • Death of anyone currently or recently
    detained in Police/Prison Custody or
    another type of state custody

Registrars of births and deaths,
doctors or police must report these
types of deaths to HM Coroner.

The ward doctor would contact the
police to advise of a death and the
police would normally inform the
Coroner’s Office.

Health & Safety
Executive (HSE)

Death, major injury or dangerous
occurrence.

Over seven day injuries Specified injuries (such as fractures, scalp injuries and some burns)

Managers have the responsibility to
ensure that the HSE are informed.
They should inform the Health and
Safety team, who will contact, on
behalf of managers, the Health &
Safety Executive see Health & Incident Type Contact (who and how).

Safety files or Health & Safety home
page (Trust Intranet).

Managers have the responsibility to
ensure that the HSE are informed
within seven days. They should
inform the Health and Safety team,
who will contact the HSE, on behalf
of managers, using a RIDDOR form
(see Health & Safety file or go to
link on the Health & Safety home
page – Trust Intranet).

National Health
Service Resolution
Incidents where the Trust becomes aware
that litigation will result
All staff through the Legal Services
Team as soon as they are aware.
01622 724100
Professional
Regulatory bodies
Incidents where there appears to have
been a breach of the professional code of
conduct.
All staff members to escalate to
managers as soon as a breach of
the professional code of conduct
becomes apparent in line with the
disciplinary policy. Managers should
escalate to Human Resources
Team and the Deputy Director of
Nursing.
Medicines and
Healthcare
Products
Regulatory Agency
(MHRA)
Incidents involving injury or risk of serious
injury involving healthcare products and
equipment
All staff, in line with the Medical
Devices Policy, must report
incidents /near misses relating to
medical devices via Datix. The Datix
Team will then report these to the
Medicines and Healthcare products
Regulatory Agency (MHRA) on-line
reporting system. A copy of the online report will then be forwarded to the Medical Devices Coordinator for information and any necessary
action.
Safeguarding
Vulnerable
Children
Any incident involving serious harm to a
child
All staff immediately via
Safeguarding processes on the
intranet
Safeguarding
Vulnerable Adults
Any serious incident involving a vulnerable
adult
All staff immediately via
Safeguarding processes on the
intranet.
Care Quality
Commissioner

All unexpected mental health related
deaths including suicides and homicides or
those where individuals have died in
hospital of a physical illness where mental
health services may have contributed.

For statutory requirements, any death of
any patient that is detained or liable to be
detained whilst in KMPT care. as well as
sending the 72 hr report, I also

Reported by the Quality and
Compliance Manager as informed
by the SI and Mortality Panel.
Environmental
Health/Food
Standards
Agency/Public
Health England
Incident involving contaminated food
products resulting in illness
All staff to escalate incidents
immediately to the Infection Control
team and Estates as soon as
identified. The former would
escalate to Public Health England.
Local Community Any incident that is likely to impact on the
local community
The SI and Mortality Panel will
determine other organisations e.g.
KCC, other Trusts, charitable
organisations, police to be
contacted and who would lead the
communication. This may need to
be in consultation with executive
staff.

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.