ADULTS’ HEALTH & CAREDEPARTMENT No 03/17
SERIOUS INCIDENT POLICY
Version 2
Effective date / August2017
Category / Adults
Summary / This document provides a guide to staff on the reporting, management and reviewing of incidents including serious and critical incidents
Keywords / Critical incident reviews, investigations, near misses, serious incidents, learning
Approved by / Care Governance Board
Date Approved / August 2017
Procedures cancelled or amended / Critical Incident Review Policy and Serious Incident Policy Version 1
Author / Alison Ridley, Learning and Review Manager, Safeguarding, Quality and Governance Team
Sponsor / Care Governance Board
Contact / Alison Ridley, Learning and Review Manager
or Karen Alexander, Strategic Service Manager, Safeguarding, Quality and Governance Team.
Signed
Designation
Date / Jo Lappin
Head of Safeguarding and Governance
18/10/17

PURPOSE

The purpose of this procedure is to outline the process for reporting incidents relating to service users and staff members, and for reviewing and learning from serious and critical incidents. There is a separate Reviewer’s Handbook which provides additional practical guidance for those people who are undertaking the review process.

SCOPE

A serious incident may require investigation when someone in receipt of social care support dies unexpectedly or experiences significant harm. Where someone has died or suffered serious harm we are accountable for effective governance and learning from what has happened. We also have a duty to support family and carers and provide information. A serious incident may also involve member(s) of staff or member(s) of the public if it occurs on our premises or if the service is directly implicated. This policy extends to near misses where it is likely that significant harm or death could have occurred.

REFERENCES TO LEGAL, CENTRAL GOVERNMENT AND OTHER EXTERNAL DOCUMENTS, INCLUDING RESEARCH

Care Act 2014 (section 42 – 44) Statutory Guidance

Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Learning, candour and accountability (December 2016) Care Quality Commission

Pan Hampshire Safeguarding Adults Policy (May 2015)

HAMPSHIRE COUNTY COUNCIL AND ADULTS’ HEALTH & CAREDEPARTMENT REFERENCES

Duty of Candour Policy

Debrief Staff Support guidance

Death of a Service User policy.

AUTHORITY TO VARY THE PROCEDURE

Care Governance Board

Departmental Management Team

Contents

Section 1 – Purpose Page 5

Section 2 – Definition of Incidents Page 5

Section 3 – Incident reporting processPage 6

Section4 – Duty of CandourPage 8

Section 5 – Types of reviewPage 8

Section 6 – Critical Incident Reviews – guiding principlesPage 9

Section 7 – The CIR process and flowchartPage 10

Section 8 – Support for the reviewing processPage 14

Section 9 – Joint agency reviewsPage 14

Section 10 – Multi-agency reviews and SARs Page 14

Section 11 – Gaining and embedding the learningPage 15

Section 12 –De-briefing ServicePage16

Section 13 – Parallel Process and statutory reviewsPage 17

Appendix A – Immediate Action after a Critical Incident Page 20

Appendix B – Critical Incident Review templatePage 21

Appendix C – CIR Action Plan formatPage 22

Appendix D – Other types of reviews for serious incidentsPage 22

  1. PURPOSE

This procedure sets out the governance framework for reporting incidents of harm that occur to service users and staff members. It also provides guidance on the processes of reporting, managing, reviewing and learning from the most serious incidents.

Most of the time people receive safe and effective services from Adults’ Health & Care which are delivered to a high standard.However, sometimes service users experience poor outcomes or incidents happen that require investigation or review to understand how and why something happened toinform learning and changes that willreduce the risk of it happening again in the future. Poor outcomes can happen for many reasons and it is not necessarily the case that services failed or that there was individual human error. Often there are underlying systemic factors that have influenced the circumstances and outcomes. It is important to learn what we can from each incident in order to improve practice and systems. Incident reporting is an integral part of Care Governance and forms part of the overall Safeguarding and Governance approach for the department.

The purpose of this framework is to:

  • Provide guidance on reporting incidents of harm that occur to service users and staff members
  • provide guidance on the response that is required in such situations
  • outline the reporting and governance arrangements for reviews and investigations of serious incidents and critical incidents
  • clarify roles, responsibilities and timescales.
  1. DEFINITION OF INCIDENTS

A serious incident can be defined as an incident which resulted in one or more of the following occurring:

  • unexpected death or severe harm to one or more service user(s), staff or members of the public whilst in receipt of a service from Adults’ Health & Careor occurring on HCC premises
  • an incident that prevents or threatens to prevent the ability to provide a safe service – such as data loss or property damage
  • loss of confidence in the service, adverse media coverage or public concern about the service provided by Adults’ Health & Care.

A critical incident can be defined as incidents with the most severe consequences i.e. where death or serious injury or harm has occurred. (These equate to category red incidents in relation to the in-house reporting system).

  1. INCIDENT REPORTING PROCESS FOR IN-HOUSE PROVIDER AND COMMUNITY SERVICES

Immediate management of an incident

Priority should be given to ensuring the welfare of all those involved and making sure a safe environment is established.Objective and contemporaneous records should be kept of the details of the incident when it is safe to make a record. A checklist of actions to be taken immediately can be found at Appendix A.

Reporting incidents

All incidents of harm or injury (including emotional abuse) to service users and staff members should be reported to the Safeguarding, Quality and Governance Team through the Adults’ Health & Careincident reporting system. This enables a consistent approach, clear governance and accountability and the opportunity for service improvements and adjustments to be made continuously.All regulated services provided by Adults’ Health & Careshould also notify the Care Quality Commission in line with the reporting requirements set out by CQC.

The electronic incident reporting form should be downloaded from the Health & Safety website at the following link: which can be found under the heading ‘Incident/Critical Incident Reporting’. Once completed it should be sent to the incident reporting inbox SSHQRCIN.

Incidents in relation to staff members

Managers should also consider making a referral for a debriefing for the team in cases where a traumatic incident or traumatic chronic case has had an impact on team members. This can be discussed with the Strategic Service Manager, Safeguarding, Quality and Governance Team.

Incidents in relation to service users

All incidents of harm or injury to service accessing services commissioned or provided by Adults’ Health & Careshould be reportedto the S,Q & G Team via the incident reporting inbox SSHQRCIN. Where a service user has been harmed and abuse or neglect is suspected, a safeguarding alert should be raised. If a crime is suspected the police should be contacted.

Reporting incidents of serious harm to service users or unexpected death

Within in-house provider services all unexpected service user deaths should be reported. Many will not require further review. Where deaths where expected or explainable they should not be reported.

Within cases held by community teams where the service user’s case was open to HCC and/or receipt of services commissioned by HCC at the time of the serious injury or unexpected death, and there is concern that the quality of service provision was not adequate, the DSM should contact the Strategic Service Manager,Safeguarding, Quality and Governance Team to discuss the referral and consider the most appropriate response required to review the case.

Referral to the Safeguarding, Quality and Governance Teamshould be made for the attention of the S,Q & G TeamStrategic Service Manager by telephone or email at :

Safeguarding in relation to injuries and unexpected deaths

There may be occasions when an injury to a service user is suspected to have involved abuse or neglect in which case a safeguarding enquiry would usually be opened. Safeguarding practice guidance is available at Report Abuse | Hampshire Safeguarding Adults Board and the internal guidance SCPM Safeguarding adults at risk .

In some instances a Critical Incident Review might also be commissioned and it could provide the investigation report submitted as a part of the section 42 enquiry.

Unexpected deaths should not usually be investigated using the safeguarding process, as it is primarily intended to be used as a vehicle to work actively in partnership with the service user to prevent harm. The Critical Incident Review process or other form of reflective review would be more appropriate vehicle for exploring what can be learnt from an unexpected death. Depending on the circumstances of the death it may meet the criteria for a SAB multi agency review or a statutory Safeguarding Adults Review (SAR) (see section10 for details) .

Grading of incidents

All incidents are graded according to severity using RAG (Red, Amber, and Green) colour coding. This grading is directly related to the categories of injury and incident selected by the person completing the incident form. The nature and severity of the incident is automatically reflected in the colour coding of red, amber or green generated as the form is completed.The completed incident reporting form will be colour coded to enable staff to have an overview of the risk presented by each incident:

Green incidents will not usually require further investigation but should be reviewed by the manager of the team in which the incident occurred, with any learning communicated to staff. The incident will be added to the incident reporting database and no further action will be taken.

Amber incidents require a local investigation to be conducted and recorded by the person in charge / manager of the team involved. The form is also sent to the appropriate Service Manager / DSM so that they are aware. Amber IR’s are also sent to a named lead for information purposes, but if they have any questions or concerns about the information they can make contact with the unit or team which submitted the incident form and follow it up as appropriate. If any new information is uncovered as part of this process, the lead should email the information to the Senior Incident Reporting Officer so that it can be added to the database. This is the end of the process for all amber IR forms.

Red incidents are the most serious/critical incidents where further investigation may be required. An initial local investigation should be conducted and recorded by the person in charge / manager. The incident form is also sent to the appropriate Service Manager (and DSM where community teams had involvement). When received they are forwarded to the Strategic Service Manager, Safeguarding, Quality and Governance to determine the level of further investigation required.

Triggering a critical incident review (CIR)

Within HCC in-house services a critical incident review will be triggered by the completion of a red, or in some cases, amber incident reporting form. The Strategic Service Manager, Safeguarding, Quality and Governance will take an immediate overview of the incident and the available information to determine if a CIR is required.

In community services a CIR can be triggered by the operational Service Manager/ DSM contacting the Strategic Service Manager, Safeguarding, Quality and Governance to refer the case. The Strategic Service Manager, Safeguarding, Quality and Governance will take an immediate overview of the incident and the available information to determine if a CIR is required.

  1. DUTY OF CANDOUR

Some incidents will trigger Duty of Candour responsibilities as set out in the department’s Duty of Candour policy. The duty of candour will be applied by Adults’ Health & Care where there is any unintended or unexpected incident that occurs in respect of a service user during the provision of a regulated or non regulated activity where the following has resulted:

  • Death of the service user, where the death relates to the incident or
  • Serious injury to the service user.

The requirement is for there to be open communication with families and carers and those affected regarding events that result in harm or death of a person in receipt of social care services.

5.TYPES OF REVIEW

The most serious incidents (those that are graded as red) require investigation. There are three different types of review response depending on the individual case, a Records Review, a Reflective Workshop or a Critical Incident Review (CIR). (Details of Records Reviews and Reflective Workshops can be found at Appendix D). The Safeguarding and Governance Strategic Service Manager is able to advise on which will be the most suitable for of review.

6. CRITICAL INCIDENT REVIEWS - GUIDING PRINCIPLES

The incident review process is underpinned by the following principles:

  • The focus of the review process is to learn from the incident to improve service delivery. Consideration will be given to supporting and reassuring staff who are involved in the review process. Reviews should be conducted in a manner which facilitates engagement and learning and allows for reflection. The process should also ensure that learning is embedded following the review.
  • The central focus of any review is to engage with the practitioners and managers who were involved in order to gain an understanding of the factors that influenced the case and led to the incident happening. The reviewers willthenmake learning recommendations about areas of work that are needed to improve systems and practice.
  • The review should be fair and balanced. The process is not used to allocate blame. It should take account of what practitioners knew or could reasonably have been expected to have known at the time. Reviews are not disciplinary proceedings. If any poor practice issues emerge that require the use of the departmental capability or disciplinary procedures, these will be conducted by the relevant line manager in liaison with the HR department, and are completely separate from the incident review process. The type of review process to be used will depend upon the circumstances of each case, and should be proportionate to the scale, significance and complexity of the issues and concerns highlighted.
  • Adults at risk and their families should always be offered the opportunity to contribute to the review and receive feedback on the learning outcomes achieved. This includes Duty of Candour responsibilities. It would be normal and best practice for the user/family members to receive a copy of the report. Where the Case Reviewers decide (in agreement with the Strategic Service Manager) that this is not possible or appropriate, the rationale for not doing this will be documented in the review report. However the user and family members should be advised that they have no right of appeal against the findings of the report.
  • CIRs relate to services commissioned by or delivered by Hampshire County Council, and are generally conducted as single agency internal reviews. We have no authority to interview staff employed by other agencies or to add conclusions into the CIR report that comment on the practice of staff from other agencies. Where the nature of the case included significant involvement by colleagues from other agencies, consideration should be given during the planning stages to whether some elements should be undertaken jointly with the other agency in order to gain a more complete understanding of the local systems and the nature of joint working that influenced the case. Thought should be given at the outset to how the governance arrangements of each agency will be met in relation to any findings.

7. THE CRITICAL INCIDENT REVIEW PROCESS

The criteria for undertaking a critical incident review

A critical incident is one where the service user is known to Adults’ Health & Careand involves:

  • an unexpected or preventable death
  • a serious assault or abuse of a service user, member of staff or member of the public
  • when serious harm or injury occurs to one or more service users, staff, or members of the public that requires intervention, or that may lead to shortened life expectancy, permanent harm, diagnosed prolonged pain or psychological harm
  • a near miss where it is likely that significant harm or death could have occurred.

The purpose of conducting a critical incident review is to:

  • understand what happened and why in that particular incident
  • review the practice and adherence to policies and procedures
  • identify any areas of learning
  • make recommendations where changes are required to systems and processes to prevent a reoccurrence in the future
  • ensure continual improvements are made to the way services are designed and delivered.

Terms of Reference

The Strategic Service Manager, Safeguarding, Quality and Governance (or the Head of Safeguarding, Quality and Governance) will agree the Terms of Reference in liaison with the commissioning Service Manager/DSM. Considerations should include:

  • the level of the investigation required
  • the methodology to be used
  • the time period covered by the review
  • the HCC staff to be interviewed
  • service user and family involvement
  • staff from other agencies to be interviewed
  • what records, policies and procedures will be included in the review.

The Terms of Reference should provide direction about the key areas of learning that are required, however should not be too prescriptive to allow the reviewers some flexibility to explore practice and systems that emerge during the review (which will not always be anticipated).

Timescales for CIRs

  • The draft report should be available within 45 days of the referral for the CIR being accepted and allocated by the Strategic Service Manager, Safeguarding, Quality and Governance.
  • The report (or a summary version) is shared with the frontline team during the period between days 45-60 at a Findings Workshop which allows the front line teams to be involved in the development of the action plan.
  • The report and action plan will be taken to the next Care Governance Working Group for sign off, and also be signed off by the Commissioning operational Head of Service.
  • The action plan should be implemented over the following months and at six months (or as soon after as a Care Governance Board meeting is being held) from the day the report was signed off, the Operational Head of Service should report back to the Care Governance Board on the progress of the actions.
  • The outcomes at six months are noted by the Senior Incident Reporting Officerin the Safeguarding, Quality and Governance Team to add to the CIR governance database.

Where operational difficulties arise, or where CIR Chairs experience delays in obtaining information from external agencies, the timescale can be reviewed by the commissioner of the CIR and the Strategic Service Manager, Safeguarding, Quality and Governance.