Public Health Commissioned Services

Public Health Commissioned Services –

SERIOUS INCIDENT POLICY AND PROCEDURES

Contents

Introduction and Purpose

Definitions and thresholds

Responsibility and accountability

2. 1Responsibilities and obligations

2.2Accountability and Governance

2.3Involvement of multiple commissioners

Reporting a Serious Incident

3.1All providers

3.2Reporting procedures

Appendices

A1 Serious Incident (SI) Reporting Form

A2 Reporting stages and timescales

A3 Root Cause Analysis (RCA) Template

CIRCULATED TO: ESCC public health senior team; commissioners of public health services; providers of public health services; ESCC communications team; and ESCC contracts and purchasing unit.

Providers should report a Serious Incident (SI) to the Public Health Business Manager who is responsible for managing the SI procedure. The Public HealthBusiness Manager will work with both the commissioner of the service and the provider to ensure the policy is followed.Contact details are listed below.

Contact / Telephone / Email
Tracey Houston
Public Health Business Manager / 01273 481932 / , and cc

For urgent notification of SI out of hours, contact the ESCC Duty Emergency Planning Officer, contact via East Sussex Fire & Rescue Service Sussex Control Centre Tel: 01444 411828 who will contact ESCC Public Health On Call. Public Health On Call will then contact the Director of Public Health or nominated deputy. Please indicate nature of incident and provide contact details for your call to be returned by Public Health.

Introduction and Purpose

Serious Incidents[1] (SI) are adverse events, where the consequences to patients, clients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified. SI include acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events[2], incidents that prevent (or threaten to prevent) an organisation’s ability to continue to deliver an acceptable quality of services and incidents that cause widespread public concern resulting in a loss of confidence in services.

The needs of those affected should be the primary concern of those involved in the response to and the investigation of serious incidents. Patients, clients and their families/carers and victims’ families must be involved and supported throughout the investigation process.

Providers are responsible for the safety of their patients, clients, visitors and others using their services, and must ensure robust systems are in place for recognising, reporting, investigating and responding to SI and for arranging and resourcing investigations. Commissioners are accountable for quality assuring the robustness of their providers’ SI investigations and the development and implementation of effective actions, by the provider, to prevent recurrence of similar incidents.

This document sets out:

1. Definitions and thresholds of a SI.
2. Responsibility and accountability for the management of SIs.
3. The SI reporting mechanisms for providers of public health services.

The reporting and management of incidents involving ESCC employees under the County Council procedures for reporting incidents and accidents at work are not within the scope of the procedure.

Definitions and thresholds

A SI is an event or circumstance that could have resulted, or did result, in unnecessary damage, loss or harm such as physical or mental injury to a patient, staff, visitors or members of the public. For the purposes of this policy, anSI is defined as an incident that occurred in relation to public health commissioned services and care resulting in one of the following:

• Unexpected or avoidable death of one or more patients, clients, staff, visitors or members of the public.
• Serious harm to one or more patients, clients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm (this includes Incidents graded under the NPSA definition of severe harm).
• A scenario that prevents or threatens to prevent a provider organisation’s ability to continue to deliver services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure.
• Allegations of abuse.
• Adverse media coverage or public concern about the service, organisation or the wider County Council or NHS.

An Incident Investigation is a process to determine the underlying reason for an incident and to identify actions to minimise the likelihood of the event recurring. The needs of those affected should be the primary concern of those involved in the response to and the investigation of SIs. Where applicable, the principles of openness and honesty as outlined in the NHS Being Open guidance[3] and the NHS contractual Duty of Candour[4] must be applied in discussions with those involved. This includes staff and patients, victims and perpetrators, and their families and carers

The scale of the investigation and the level of escalation should be proportionate to the seriousness of the incident, should include a root cause analysis[5] and recommendations to prevent a similar event occurring in the future.

1.1. Assessing whether an incident is a serious incident

In many cases it will be immediately clear that a serious incident has occurred and further investigation will be required to discover what exactly went wrong, how it went wrong (from a human factors and systems-based approach) and what may be done to address the weakness to prevent the incident from happening again. Whilst a serious outcome can provide a trigger for identifying serious incidents, outcome alone is not always enough to delineate what counts as a serious incident. Upsetting outcomes are not always the result of error/ acts and/ or omissions in care. Equally some incidents, such as those which require activation of a major incident plan for example, may not reveal omissions in care or service delivery and may not have been preventable in the given circumstances. However, this should be established through thorough investigation and action to mitigate future risks should be determined.

Where it is not clear whether or not an incident fulfils the definition of a serious incident, providers and commissioners must engage in open and honest discussions to agree the appropriate and proportionate response. It may be unclear initially whether any weaknesses in a system or process (including acts or omissions in care) caused or contributed towards a serious outcome, but the simplest and most defensible position is to discuss openly, to investigate proportionately and to let the investigation decide. If a serious incident is declared but further investigation reveals that the definition of a serious incident is not fulfilled the incident can be downgraded. This can be agreed at any stage of the investigation and the purpose of any downgrading is to ensure efforts are focused on the incidents where problems are identified and learning and action are required.

1.2. Can a ‘near miss’ be a serious incident?

It may be appropriate for a ‘near miss’ to be a classed as a serious incident because the outcome of an incident does not always reflect the potential severity of harm that could be caused should the incident (or a similar incident) occur again. Deciding whether or not a ‘near-miss’ should be classified as a serious incident should therefore be based on an assessment of risk that considers:

• The likelihood of the incident occurring again if current systems/process remain unchanged; and
• The potential for harm to staff, patients, and the organisation should the incident occur again.

This does not mean that every ‘near-miss’ should be reported as a serious incident but, where there is a significant existing risk of system failure and serious harm, the serious incident process should be used to understand and mitigate that risk.

Responsibility and accountability

2. 1Responsibilities and obligations

The primary responsibility in relation to SIs is from the provider of the care to the people who are affected and/or their families/carers.

The contractual obligation of provider organisations to report SIs is contained within the appropriate schedule of their standard ESCC contract. All providers of ESCC Public Health commissioned services should consider this procedure as contractually binding and ensure any internal procedures/policies are compatible with it.

Providers of ESCC Public Health commissioned services are contractually required to have a designated post holder and deputising post with responsibility for reporting an SI. The provider is responsible for ensuring the safety of patients/clients whilst on their premises and/or receiving the service from their staff and departments and/or throughout the whole process. The commissioner expects that they have robust risk management systems in place including incident reporting and learning, and risk assessment. It is expected that all providerorganisations will manage incidents in accordance with the National Patient Safety ‘being open’ guidance[6].

Commissioners of public health services are responsible for having a process in place to receive reports of SIs from providers. The commissioner is responsible for:

• ensuring that the provider fully understands and is able to comply with the SI Policy;
• leading or delegating relevant actions for SI management referred to within this policy;
• reviewing Root Cause Analysis reports from providers and making a decision as to whether to submit to the Public Health Senior Team to close the incident.

2.2Accountability and Governance

The Director of Public Health is accountable for developing, implementing and monitoring the systems and processes for reporting, investigation and management of SIs within public health services commissioned by ESCC. The Public Health Senior Team has the responsibility for reviewing and quality assuring the robustness of SI investigation, learning and action plan implementation undertaken by their providers. The commissioner will produce reports when appropriate to meet external requirements for SI reporting.

The commissioner is responsible for liaising with the provider risk management team and ensuring the appropriate level of investigation takes place, including any reference to the ESCC policy statement: Anti-Fraud and Corruption Strategy (July 2012). The ESCC Communications lead is responsible for managing, defining, and mitigating any reputational risk to ESCC and liaising with ESCC communications team where required. The public health business manager will log all SI, maintain an overview of any developing trends and escalate when necessary

2.3Involvement of multiple commissioners

The model of providers reporting incidents to the commissioner who commissions the contract may not always be practicable in a complex commissioning landscape where multiple commissioners may commission different services from the same provider.[7],[8]Where this scenario is identified, ESCC Public Health, as accountable commissioner, will delegate responsibility for the management of the SI to the lead commissioning body for the provider using a RASCI (Responsible, Accountable, Supporting, Consulted, Informed) approach.[9]

Using this approach, the accountable commissioner (contract signatory) will work collaboratively with and through other commissioners, to ensure the reporting arrangements are included within contracts. This means that a provider reports and engages with one single commissioning organisation who can then liaise with other commissioners as required (see Figure 1). Whilst accountable commissioners may delegate responsibilities for SI management to other commissioners they remain accountable for quality assuring the robustness of the SI investigation, learning and action plan implementation undertaken by their providers.

Reporting a Serious Incident

3.1All providers

All providers must report a SI to the Public Health Business Manager who will liaise with the commissioner of the service or the commissioning organisation with delegated responsibility for the management of SIs. Contact details are listed on the front page.

Reporting a possible SI to an external body other than ESCC does not remove the need to report the incident to the commissioner and the Public Health Business Manager and complete the SI reporting process.

Any SI reported to the commissioner involving a patient under the age of 18 will be forwarded to the ESCC child protection leads. This does not in any way override provider organisations’ responsibilities in regard to the reporting of child protection/safeguarding children issues.

The reporting of an SI does not remove the provider organisation’s responsibility for contacting any external bodies that need to be informed of the SI, including adult and child safeguarding.[10] The provider will also comply at all times with the Sussex Multi-Agency Policy and Procedures for Safeguarding Adults at Risk and undertake reporting as agreed in respect of this policy. The provider will continue to work with the commissioner to harmonise the Safeguarding Adults at Risk and SI processes and to ensure that adult safeguarding is informed by the SI investigations and that the outcomes of these investigations are shared where necessary. Similarly, the provider will work with the commissioner to ensure harmonisation of the safeguarding children processes with SI process. The provider will comply at all times with the East Sussex Child Protection and Safeguarding Procedures, including the safeguarding of adults at risk.[11],[12]

If an SI involves a number of providers and those providers are unable to agree on the organisation responsible for reporting on the SI Reporting Form, the commissioner will assign a lead organisation on the available evidence. Failure of that organisation to report on the SI Reporting Form and lead the investigation will be considered a possible breach of contract.

Events of media interest that are not SIs

If events cause media interest or have the potential to cause media interest but do not meet with the SI definition, then the provider need only report the event via phone or email to the appropriate commissioner and the Public Health Business Manager. In these cases, an SI Reporting Form should not be submitted and the commissioner in consultation with the ESCC Communications lead will decide on any further action.

3.2Reporting procedures

ESCC Public Health will commission services from essentially three types of organisations. Each organisation will have different reporting processes depending on their status and registration. Figure 1 outline’s the different processes for reporting and managing SIs. It should be noted that, as the contract holder, public health retain the overall accountability for assurance of providers SI management andreporting.

NHS organisations

NHS organisations will automatically report SI through the NHS STEIS(Strategic Executive Information System) system. These SI will be received by thePan-Sussex SI group, and will be managed through that process. The ESCC Public Health lead for Quality is a member of the Pan-Sussex SI group by exception and attends when SIs relating to ESCC Public Health Commissioned Services are discussed.

CQC registered organisations

These cover organisations who are CQC registered and as such are required to report incidents to the CQC and to the commissioner.

Figure 1: SI reporting process for ESCC public health commissioned services

All other providers

For all other providers, all SI are managed through the normal contract monitoring process. Providers should use the SI Reporting Form at Appendix 1 to record the details of an incident. The key reporting stages and expected timescales are set out at Appendix 2 together with the obligations of both the provider and the commissioner.

SIs reported from a third party: if a possible SI under the responsibility of the provider is reported to ESCC from a different source than the provider organisation, then the commissioner of the service will contact the identified provider and request investigation of the incident and a decision on SI reporting. If the commissioner has reason to believe the provider organisation had knowledge of the SI beforehand but failed to report the incident, the commissioner will record this as a possible breach of contract.

The commissioner and Public Health Business Manager will be responsible for monitoring the SI investigation and may request additional information from the provider and or higher levels of investigation, up to an external review. If the commissioner feels an external investigation is required, a request must be made to the Contract Holder. The Director of Public Health is accountable for authorising any external investigation.

Any SIs reported to the commissioner involving information governance breaches will be reported to the ESCC Information Governance Lead.The provider will forward to the appropriate professional lead any SI that identifies possible professional misconduct or professional negligence by a registered health care professional. The commissioner and the Public Health Business Manager will ensure compliance with timescales for SI and Root Cause Analysis (RCA) reporting.

The commissioner willrequire the provider to:

• produce the provider SI policy within five working days of the request;
• produce an action plan within ten operational days of a request to do so; and/or
• submit further reports within ten operational days of a request to do so; and/or
• attend meetings with regard to implementation of the action plan within ten operational days of a request to do so.

At the point the provider organisation has completed investigation it should update the SI Reporting Form with the date the investigation was completed. The full investigation report should be sent electronically and securely to the commissioner and the Public Health Business Manager within the timescale. All RCA reports and action plans should be submitted according to the format in Appendix 3. The report should not contain person or patient identifiable information. If there is concern that a patient, staff member or member of the public may be able to be identified from the report, the provider must arrange and confirm with the commissioner how to send the report to a secure email account.

The Public Health Senior Team will decide whether to close a SI reported by a provider.[13] The commissioner of the service will present the investigation report and recommendation for closure to the Public Health Senior Team for consideration.