SWL Cluster Process for Managing Serious Incidents (SIs)

Reporting Serious Incidents (SI) to the NHS SWL Management Team in advance of Joint Boards (Revised October 2011)

The purpose of this paper is to provide guidance on process for notifying new Serious Incidents (SIs) to the Management Team and the Joint Boards; and where SIs have been completed, to provide summary reports on findings and action plans. The Management Team and the Joint Boards will be seeking assurance from the relevant Borough/Cluster Team that the investigations are completed and action plans implemented within agreed timescales (NHS London timescales, where applicable).

All Serious Incidents notifications, including potential SIs, will be reviewed by the NHS SWL Management Team in advance of notification to the Joint Boards.

This process is based on the notion that:

  1. Potential Serious Incidents are being reported at local MT meetings and filtered by the Borough Managing Directors for reporting to SMT.
  2. For further advice/input before declaring a SI, consultation is carried out in advance of declaration where possible, as follows:
  1. Clinical incidents (Actual or Potential): SWL Nursing Director / Medical Director for clinical input before reporting the SI to NHSL or by contacting Governance & Risk Manager
  2. Information Governance: NHS SWL SIRO (Senior Information Risk Owner) or Cluster Information Governance Manager
  3. Health and Safety, Fire and Security – e.g. slips, trips and falls, fire incidents, thefts and damage to the trust property etc. – with Head of Strategic Asset Management or Health and Safety Advisor
  1. Boroughs have arrangements in place for dealing with SIs, tracking, undertaking investigations and reporting SIs to NHS London via StEIS
  2. Boroughs have arrangements in place for ensuring that recommendations and action plans are implemented and assurance provided to the Clinical/ Integrated Governance Committee CIGC and the Joint Boards
  3. Boroughs disseminate wider learning identified from SIs.
  4. Potential SIs are also reported / recorded on Datix (NHS SWL Risk Management System for reporting incidents).

Notifying SIs to the SWL Management Team / CIGC / Joint Boards

  1. Notifications

The Management Team will receive SI notification reports from Boroughs /Directorates on exceptional basis. For the purpose of reporting SIs to Management Team and Joint Boards, StEIS numbers (where available) will be used for reference and tracking. Potential SIs, which had not been reported via StEIS, will be notified using DATIX reference numbers.

The SMT will receive assurance on initial management and investigation of SIs.

The template for notifying SIs is attached in appendix 1

  1. Tracking SIs

The template for tracking SIs is attached in appendix 2.

The template will help track progress with completion of investigations. There is a national requirement (National Framework for Reporting SIs – NPSA) that investigations are completed and closed within 45 working days; the timescales being actively performance managed by NHS London. The CIGC will monitor significant delays with a view to facilitating the process and/or seeking assurances. It is proposed that only the tracking report is received by CIGC.

  1. Completed Investigations / Closure Reports

The Boroughs / Directorate will present draft reports of completed SI investigations with an executive summary to NHS SWL SI Monitoring Panel(SIMP) for discussion and agreement in advance of Joint Boards leading to:

  • Closure of the Report
  • Executive, Board level sign off by the SWL Medical Director / Nursing Director
  • Boroughs sending the agreed report to NHSL () for closure
  • Reporting to Part 2 of the CIGC and Joint Boards

Draft ToR of SI Panel are attached in Appendix 3

For forwarding reports/ information on SIs to Governance and Risk Team, please use secure email address: and copy to

Potential SI

Clinical /SIRO/H&S Input

1Notification should be sent to Care Quality Commission within 5 working days of the Local Safeguarding Children’s Board’s confirmation to proceed with the review, see

2 Email draft and final reports to Medical Director/ Director of Nursing Office via and copy to

Timescales requirement according to Grade of SI (Source: *National Framework for Reporting and Learning from Serious Incidents Requiring Investigation - NPSA, 2010)

Appendix 1

Template for Notifying Serious Incidents to SWL Corporate Affairs Team

STEIS number and date of reporting
Borough involved
Contact details of lead manager handling the SI / Name:
Job Title:
Telephone:
E-mail:
When did the incident occur? / Date: / Time (24 hr clock):
What happened? (Please give a brief account of the incident, including details about the staff involved).
Other information not in the public domain
Describe any immediate action taken to minimise risks
Information about actual or likely media interest, including draft response/line to take

Secure email address: or

Document Control: Mohammed Sheikh1Version: 8 Dated: 25.01.2012

Appendix 2

Template for Tracking Serious Incidents and Reporting to Clinical Integrated Governance Committee/ Joint Boards

STEIS No / SI Title or Brief Description / Borough / SI Reporting Date / Lead Investigator / Current stage of investigation / Date when closure is due / Days overdue / Key Issues (which have or may delay the investigations)

Document Control: Mohammed Sheikh1Version: 8 Dated: 25.01.2012

Appendix 3

Terms of Reference of NHS SWL SI Monitoring Panel (SIMP)

  1. Purpose

1.1The ‘SIMP’ provides opportunity to consider how the SI Investigation report will be presented to the Clinical/ Integrated Governance Committee (CIGC) and the Joint Boards, and give an added assurance that report has been considered internally.

  1. Scope

2.1To provide this assurance in respect of SIs for NHS SWL Cluster, both as a corporate/commissioning organisation and for the legacy SIs which relate to Community Services of 5 PCTs which are yet to be closed.

2.2The ‘SIMP’ does not review closure reports in relation to commissioned services. The responsibility has been delegated to the Clinical Quality Review Groups from the PCT Boards to monitor SIs in commissioned services as part of the commissioning contract arrangements.

2.3The Safeguarding Children Overview Group will be responsible for providing the review function for Serious Case Reviews/Individual Management Reviews (IMRs).

  1. Accountability

3.1The ‘SIMP’ is accountable to the CIGC and any risks associated with the incidence of SIs and/or the associated investigation will be raised on the Corporate Risk Register / Board’s Assurance Framework.

The CIGC also has a role in scrutinising SI closure reports as remitted by the Board - either in advance of or following Board consideration.

  1. Membership

Chair – Director of Nursing / Sarah Timms
Associate Medical Director Sutton / Dr Paul Alford
Associate Director of Corporate Affairs / Elaine Newton
Governance and Risk Manager / Mohammed Sheikh
Lead investigating officer / For each SI
Invited Members (appropriate to the SI)
This might include Borough Medical Director, Lead Director, SIRO; Director of Public Health, other senior managers or ‘specialist’ staff as deemed appropriate.
  1. Quorum
  2. In order for a meeting of the ‘SIMP’ to be quorate, the following must be present:
  3. Associate Medical Director or Director of Nursing
  4. Head of Corporate Affairs or Governance & Risk Manager
  5. SI lead investigating officeror a senior manager/senior clinician familiar with the investigations.
  1. Duties

6.1To consider SI closure reports in advance of their presentation to the CIGC and the Joint Boards for approval.

6.2To ensure robustness of the process undertaken for investigations and compliance with National Framework/ Local SI policy.

6.3To ensure recommendations are robust and feasible and ‘fit’ with organisational context.

6.4To ensure robust mechanisms and governance structures are in place for implementing the action plan, with follow up and dissemination of organisational learning.

  1. Reporting Arrangements

An action log will record the outcome of the ‘SIMP’ and complete a checklist to ensure compliance with the NHS L reporting template.

  1. Frequency of Meetings

A ‘SIMP’ meeting will be convened once every quarter to monitor closure reports and follow-up actions. A ‘SIMP’ meeting may be convened by the Chair at the request of lead investigator. The lead investigator should give an advanced notice of at least two weeks when a SI closure report is to be presented for review.

  1. Support

The Panel will be supported by the office of Medical Director/Director of Nursing.

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