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

6. Investigation and root cause analysis

6.1 When the serious incident is a homicide, inpatient suicide, child death, Never Event or likely to attract significant public interest, the case must be escalated to the Head of Patient Safety or Deputy Director Quality and Safety as soon as it is known, who will then alert the Chief Nurse.

6.2 An initial review will be carried out by a member of the patient safety team as appointed by the Head of Patient Safety or Serious Incident and Complaints Investigation Lead in conjunction with the appropriate care group patient safety lead. This must be completed as soon as possible after the incident has been recognised and no later than one working day from recognition of the incident. That person must be available for the IMR.

6.3 An initial IMR meeting will be arranged by the Head of Patient Safety or deputy, inviting all staff considered to be required. This will be determined in collaboration with the Deputy Director of Quality and Safety. A representative of the communications team must be included. This should be held within one working day of the incident being recognised if required.

6.4 The Lead Serious Incident and Complaints Investigator will appoint a member of CIT as a potential lead investigator for if the case is reported on STEIS, and to be available to attend the IMR.

6.5 The IMR will be chaired by the Chief Nurse or deputy and a note taker will be appointed by the Head of Patient Safety. Notes will be sent to the attendees within one working day to allow for actions to be undertaken in a timely manner.
6.6 The meeting will follow the format in appendix 2.

6.7 The IMR will determine the investigation team. It may be necessary to appoint an external investigator to support the internal investigating team. This will be approved by the Chief Nurse.

6.8 Information will be provided to the panellists of high-profile cases as per appendix 7

6.9 The CIT support officer will take notes at high profile investigation meetings.

6.10 The Chief Nurse or deputy will be responsible for escalating cases to the CQC, NHSE/I and CCG as required.

6.11 For mental health related homicide investigations, see appendix 13.