Serious Incident Policy
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Equality Statement
Vita Health Group aims to develop and implement policies and procedures that equitably meet the diverse needs of our service users, colleagues, and the wider population. We acknowledge and value difference and are committed to anti-discriminatory practices taking into account the Equality Act 2010, and Public Sector Equality Duty.
Vita Health Group conducts equality impact assessments on all organisational policies and services, ensuring consideration of protected groups’ differing needs. Vita Health Group aims to create a safe and inclusive environment for all and therefore this document has been assessed to ensure that it does not discriminate.
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All healthcare providers, whether the National Health Service (NHS) or independent organisations, provide services, treatment, and interventions for millions of people every year. Although most of these people receive safe and effective care, there are times when things go wrong, leading to some people being harmed no matter how professional and dedicated the healthcare workers are, or how safe and robust organisational support systems and processes are.
An essential foundation to improving the safety of services is through identifying and responding to service user safety incidents. It is good practice for all colleagues to recognise and report all incidents, to ensure that learning and improvement takes place as a continuous ongoing cycle. This is inclusive of all incidents that occur as well as near misses and never events. This requires healthcare organisations to recognise the needs of those affected, examine what happened to understand the causes and respond to the findings with action to mitigate the risks identified.
The NHS Serious Incident Framework outlines the importance of taking a whole-system approach to quality, where cooperation, partnership working, thorough investigation and analytical thinking are used to understand where weaknesses or problems in services or care delivery exist, and to draw upon learning that minimises the risk of future harm.
To support the NHS in ensuring there are robust systems in place for reporting, investigating, and responding to Serious Incidents, there are two national frameworks that this policy aligns with:
Vita Health Group (VHG) recognises that these frameworks are due to be replaced by the ‘Service user Safety Incident Response Framework’ https://www.england.nhs.uk/service user-safety/incident-response-framework/ in 2021 although the existing frameworks should continue to be followed on the advice of NHS England and NHS Improvement.
This policy and the procedures which sit alongside it, support colleagues to navigate the system of serious incident reporting, investigation and associated lessons learned within the organisation.
It sets out how serious incidents should be reported, managed, and investigated within VHG as well as in collaboration with external agencies and key stakeholders outside VHG.
Serious Incident
Serious incident management is a critical component of corporate and clinical governance. Serious incidents are events where the potential for learning is so great, or the consequences to service users, families and carers, colleagues or organisations are so significant, that they warrant using additional resources to mount a comprehensive response.
Serious incidents can extend beyond incidents which affect service users directly and include incidents which may indirectly impact service user safety or an organisation’s ability to deliver ongoing healthcare. The occurrence of a serious incident demonstrates weaknesses in a system or process that need to be addressed to prevent future incidents leading to avoidable death or serious harm to service users or colleagues, or future significant reputational damage to the organisations involved.
Further detail on what constitutes a Serious Incident is located at Appendix A.
Near Miss
An incident which has the ability to cause harm, but was prevented ahead of any harm occurring, through early detection, intervention, or treatment.
Never Event
Never Events are service user safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and have been implemented by healthcare providers. The NHS England Never Events policy is available here: https://www.england.nhs.uk/wp-content/uploads/2020/11/Revised-Never-Events-policy-and-framework-FINAL.pdf
Senior managers, team leads, and service leads are responsible for:
The local manager is the line manager or another immediate manager who is best suited to initially managing a Serious Incident. They are responsible for:
All colleagues may have a variety of responsibilities in the event of a Serious Incident; however, the reporting person has a specific role or tasks to complete that include:
6.1 Principles of Serious Incident Management:
Open and Transparent
The needs of those affected should be the primary concern of those involved in the response to and the investigation of serious incidents. The principles of openness and honesty as outlined in the VHG Duty of Candour Policy must be applied in discussions with those involved. This includes colleagues and service users, victims and perpetrators, and their families and carers.
Preventative
Investigations of serious incidents are undertaken to ensure that weaknesses in a system and/or processes are identified and analysed to understand what went wrong, how it went wrong and what can be done to prevent similar incidents occurring again.
Objective
Those involved in the investigation process must not be involved in the direct care of those service users affected nor should they work directly with those involved in the delivery of that care. Those working within the same team may have a shared perception of appropriate/safe care that is influenced by the culture and environment in which they work. As a result, they may fail to challenge the ‘status quo’ which is critical for identifying system weaknesses and opportunities for learning.
Timely and Responsive
Every case is unique, including: the people/organisations that need to be involved, how they should be informed, the requirements/needs to support/facilitate their involvement and the actions that are required in the immediate, intermediate, and long-term management of the case. Those managing serious incidents must be able to recognise and respond appropriately to the needs of each individual case.
Systems Based
The investigation must be conducted using a recognised systems-based Root Cause Analysis (RCA) investigation methodology that identifies what happened, how it happened, and why it happened, considering the following causes:
Proportionate
The scale and scope of the investigation should be proportionate to the incident to ensure resources are effectively used. Incidents which indicate the most significant need for learning to prevent serious harm should be prioritised. Determining incidents which require a full investigation is an important part of the process and ensures that organisations are focusing resources in the most appropriate way.
Collaborative
Serious incidents often involve several organisations. Organisations must work in partnership to ensure incidents are effectively managed.
The aims of serious incident management are to ensure that every serious incident has a detailed and thorough investigation which includes:
The following incidents or near misses are categorised as Serious Incidents:
The following actions should take place as soon as the incident is discovered.
The colleague who discovers or is informed about the serious incident (the “reporter”) is responsible for:
The Local Manager is responsible for assessing the situation and taking appropriate immediate action to:
In some extreme cases, a Serious Incident may require criminal investigation. For example, if there has been a death, or if criminal activity is suspected.
In this instance all colleagues should preserve evidence. Where a SI involves a death or serious injury the location should not be disturbed except to deliver first aid or resuscitation attempts.
In the event of serious incidents where significant harm is caused then it is likely external organisations will require involvement/notification, this will depend on the situation/pathways outside the organisation, at local, regional, and national levels.
The following actions must be completed within the first 24 hours after a Serious Incident:
Concurrently to the immediate action being completed, the Local Manager should:
The Directors and Leadership Team will nominate an:
The Incident Manager is responsible for coordinating further communications, including to:
Serious Incidents involving Safeguarding must be investigated by the Local Safeguarding Children Board (LSCB) or Local Safeguarding Adult Board (LSAB), and the Local Authority may also have a statutory duty in this regard.
These bodies should be informed in this event. In some circumstances a Serious Case Review or Safeguarding Adult Review will be commissioned and led by these boards.
The Incident Manager will ensure communication links following both VHG’s serious incident process and local safeguarding procedures as articulated in the local multi-agency safeguarding policies and protocols. VHG’s Incident Manager will liaise regularly with the commissioners and the Local Authority Safeguarding Lead to ensure that there is a coherent multi-agency approach to investigating and responding to safeguarding concerns, which is agreed by relevant partners.
See the Adult Safeguarding Policy and Child Safeguarding Policy for further details.
Managing a Serious Incident starts immediately following an incident and continues until the risk of further incidents has been sufficiently mitigated. Each Serious Incident is likely to be unique and the Incident Manager should focus on the following:
Prevent
Prevent recurrence of the same or similar issue. The following principles of issue management should be considered; Engagement – including the right people in decisions as early as possible; Speed – Quick action ensures that issues are dealt with, and processes or procedures can be altered or implemented to prevent recurrences; Decisiveness – Decisive action may be required to prevent further incidents, especially in conditions of uncertainty. Operational impacts of decisions must be weighed against the possible severity of outcomes.
Statements should be obtained from all relevant colleagues as soon as possible after an incident ideally within the first 48 hours and from service users and members of the public if required. The Investigating Manager may call an immediate response meeting where the competency or fitness to practice of any VHG colleague is called into question involving clinical, operational and HR representation to agree a fair and proportionate way forward. A written statement template is available on the intranet.
The Investigating Manager should work closely with the Incident Manager and ensure that audit trails and timelines are collated quickly and accurately. The Investigating Manager, in liaison with relevant senior managers/directors will decide on the type of investigation to be undertaken:
Part of the Investigating Manager’s report will include an assessment of the risk associated with the incident both at the time and following remedial action. The below table is a guide as to how this is assigned a numerical value:
Guidance for undertaking an internal investigation is available on the company Intranet and advice can be sought from the GQRC and the senior Governance Team.
Following the internal investigation, a written Root Cause Analysis (RCA) report will be prepared using Root Cause Analysis methodology (template available on the intranet). If a serious incident is likely to give rise to a legal claim against the organisation, advice may be sought from the company or professional indemnity solicitors, and / or the relevant professional body (CSP/HCPC/NMC/BABCP/BACP). Professional indemnity insurers must be notified.
An investigation into a serious incident is entirely separate from the organisations Disciplinary Procedures. However, if matters come to light during an internal investigation which necessitate disciplinary action in respect of a member(s) of colleague, then these matters will be dealt with separately under the organisation’s Disciplinary Procedures.
The primary goal of a SI investigation should be learning from our mistakes to improve our services and prevent future recurrences.
Learning from incidents should be widely shared with colleagues and within their team involved via a variety of different methods:
Learning across the organisation is also important and should be undertaken through a variety of methods:
All Serious Incident investigations should be reviewed by the GQRC in a timely manner but no later than three months after the incident was initially reported. The GQRC will capture this as part of the RCA actions log for shared learning.
This policy will operate within VHG’s framework for mental capacity.
This policy will be covered as part of induction processes and available via the intranet for all VHG colleagues’ reference.
Additional training may be required in conjunction with incident reporting, incident trigger lists and risk management.
There is no additional financial impact resultant from the review and update to this policy. All colleagues will be made aware of updates regarding the introduction and/or amendment to this policy through:
The Head of Governance has overall responsibility for ensuring the annual audit of this policy. Any gaps in compliance will be reported to the GQRC.
A Serious Incident may include:
Acts and/or omissions
Acts and/or omissions occurring as part of healthcare (including in the community) that result in:
Actual or alleged abuse
Actual or alleged abuse including
Where:
Never events
A Never Event - all Never Events are defined as serious incidents although not all Never Events necessarily result in serious harm or death.
Incident impacting quality of service
An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
Incident leading to harm / potential harm
An incident involving unexpected potential or actual harm or injury to service users, colleagues, or visitors (including contractors). This will include near misses and death following such an incident. The following examples should be considered when determining whether an incident is serious:
This is not an exhaustive list; it highlights the key areas which would warrant the reporting of an incident within the organisation.
Clinical or Safeguarding issues out of hours will be managed by the Duty Team. If an issue is Business Critical (or if a Clinical or Safeguarding issue includes a Business-Critical element the EMT Escalation process should be followed. An EMT Escalation Schedule is published on the intranet providing the name and contact details of the EMT member nominated to cover that month if the issue occurs Out of Hours.
Business Critical Examples (this is not an exhaustive list):
Flow diagram for escalation of Potential Business Critical Issues both in Office Hours and Out of Hours can be found below: