Incident and Serious Incident Policy

1.         Introduction

The following procedures have been drawn up to help Ayurva staff in the event of a death, or a serious incident involving a Student, Staff Member or Volunteer.  The aim of this policy is to provide a rapid, flexible, and sensitive response to major incidents which draws on skills available across the organisation and on the expertise which has been built up by staff dealing with previous incidents.

2.         Purpose

It is a mandatory requirement for training and health care organisations, such as Ayurva, to have in place incident reporting policies and procedures.  This is an important part of good risk management and is included in the NHS Litigation Authority’s (NHSLA) Risk Management Standard.

This policy and procedure covers management, reporting systems, analysis and learning from incidents. 

3.         Policy statement

This policy will be operated within a learning environment, where lessons are learned and quickly acted upon in a positive and constructive way.  The Board actively promotes a non-punitive approach to incident reporting and Ayurva will fully support any individual reporting an incident.  In many instances, the root causes of incidents lie in the management and organisational systems that support the delivery of treatment and care.  In this case, blame cannot, and should not, be attributed to individuals. The essence of the Ayurva reporting procedure is to identify and address the underlying causes of incidents.  All incidents will be investigated and managed in a sensitive and non-punitive manner. 

Disciplinary procedure will only be considered in the following cases:

• Repeated error involving the same individual.
• Deliberate failure to report an incident.
• Failure to cooperate with an investigation.
• Criminal actions.
• Actions so far removed from reasonable practice that any competent practitioner or member of staff would have been able to predict the outcome reported.

4.         Definition of a Serious Incident

Listed below are examples of serious incidents:

• Self harm
• Suicide Attempt
• Psychological Breakdown (eg: schizophrenic episode)
• Fire
• Outbreak of a serious and infectious disease
• Death

It is important to note that this is not an exhaustive list.

5.         Link to strategic objectives

It is mandatory that training and health care organisations have in place policies and procedures relating to the reporting of both clinical and non-clinical related incidents.  The requirement for incident reporting policies and procedures can be found in the NHS Litigation Authority’s (NHSLA) Risk Management Standards and the Standards for Better Health.  It is Ayurva’s objective to achieve compliance with both.

6.         Risk implications

This Policy and Resource Pack is a key part of Ayurva’s system of internal control; not adopting and implementing this would place Ayurva at risk.

7.         Equality issues

The Incident Policy and Resource Pack are part of the Ayurva risk management framework.  Good risk management practice is built into all the activities of Ayurva including our work to reduce health inequalities.

8.         Consultation and communication

Service users, carers and local people have not been involved in developing this Policy.  They have been discussed in detail at management meetings where all staff are represented.  All staff become aware of this policy during their induction phase when in employment.

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• 9.         Responsibilities

The Senior Management Team

The Ayurva Senior Management Team (SMT) is responsible for pursuing the aims and objectives of risk management including incident reporting.  The SMT has overall responsibility for the management of risk within Ayurva.

The incident reporting policy and procedure applies equally to all members of the SMT.  It is the SMT’s responsibility to ensure risk management processes, including incident reporting procedures, are in place in every department. 

Line Managers

The line manager, often the Senior Lecturer of a course, is the first point of contact for staff that have witnessed an incident.  Line managers must:

• assist staff when completing risk assessments for incidents and develop and implement action plans.
• promote a culture where it is acceptable and safe for staff to report incidents.
• provide support for staff following an incident, which may include referral to Occupational Health.

Staff must be aware of deputising arrangements for when line managers are on leave or unavailable.  This includes on-call cover.

Individual staff

Individual staff are responsible for reporting incidents (including near misses) appropriately and assisting in any incident investigations, which may require their assistance. This includes:

• Allemployees of Ayurva
• Bank and agency staff
• Self employed alternative tutors, professional visitors and/or therapists
• All Volunteers

Every member of staff must be aware of this incident reporting policy and procedure.  Staff must be familiar with Ayurva policies and should complete induction, local and external training to ensure continued competence when carrying out their duties.

 

 

10.     Stages to follow in the event of a Student, Staff or Volunteer death or Major Incident

 

 

Inform the On-call SMT Member of the incident/death

Information of an incident can reach the on-call via many points of entry, eg: any staff, other Students, volunteers, other professionals, or members of the public. Whatever the point of entry it is important to inform the management or on-call, who can facilitate a response or help in supporting a response. The on-call contact number is listed in this policy.

 

 

Facilitating a Response

The appropriate staff, e.g. the on-call SMT or manager, should then contact the SMT to inform them of the incident.

 

 

Alerting relevant agencies within and outside Ayurva

It is management’s responsibility to inform the relevant referring agency and family of those affected by the incident. Students should be informed of the help that can be provided by Ayurva.  The manager may also need to contact external agencies such as the police, or religious groups etc.

Finally, in the case of death, the manager should ensure that all relevant administrative offices know about the death and change records accordingly.

 

 

Supporting the Response

Typically, in the event of a death, the family will want to come up to the clinic and/or sober living house and to pick up the effects of the deceased. Ayurva, through the Board, can offer accommodation, food and support when this occurs.

 

 

Funerals

Ayurva will support Students and staff alike to attend the funeral of a deceased Student, where permitted by the deceased Student’s family.

 

After the Funeral

It may be appropriate for some form of community remembrance to take place. Such an act of remembrance may take many different forms, from the planting of a tree, to the development of a non-religious service of remembrance, to a full religious memorial service. Ayurva’s Board will assist in the planning of this, where appropriate.

 

 

Special Circumstances

The management team will take necessary action and will draw on specialist advice as necessary eg: support following an outbreak of meningitis (for which special procedures involving Public Health are in place) or in the event of the death of an international Student etc. In certain circumstances, it may be necessary or thought advisable to invoke Ayurva’s Emergency Plan. In such cases the on-call will liaise, as appropriate, with the SMT who will take responsibility for managing Ayurva’s response to the immediate situation.

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• 11.       Incident report form

Ayurva has one Incident Report and Risk Assessment Form (Appendix 1).  All incidents are reported using this form, including incidents that are:

• Clinical governance issues, for example incidents concerning the clinical care of patients.
• Information governance issues such as breaches in confidentiality both for patients and for staff.
• An impact on the health and safety of Students, staff and the general public using our services.

The Incident Reporting and Risk Assessment Form is in three parts: 

1. The first part requires details of the incident, what happened, when, and who was involved. 
2. The second part is Ayurva’s Risk Assessment Form. This part requires a risk score to be given using Ayurva’s Risk Assessment Matrix.  Existing control measures, care plans and action plans for new controls and resource implications are recorded in this part.
3. The third part is a page where action plans are written, showing a structured way of documenting action to be taken following an incident and to minimise risk.

1. 12.       Implementation and training

All Staff:  An introduction to incident reporting is included in the Ayurva induction programme.

Incident reporting training will be provided to existing staff through team meetings and professional staff group meetings.

Managers: Specific training in incident reporting, grading, investigating and undertaking root cause analysis will be provided for Managers and the Board.

12.       Serious Incident Evaluation

Part of every serious incident should include a serious incident evaluation and ensuring this can take place in a timely manner (recommendations are between two and four weeks’ post incident). 

An incident evaluation will be facilitated by a senior manager and will involve all staff and Students involved in the incident.  The goal of all evaluations is to gain full understanding of the event, implement any actions (such as identified in the disciplinary policy) and to identify any learning points for the incident.

13. On-Call Number

The on-call number for Ayurva is 0759 380 9574.

Appendix 1

Incident and/or Risk Assessment Form

Guidelines:

• This form should be used regarding Ayurva’s incident reporting policy & procedure and the Ayurva Risk Management Strategy.
• If the form relates to a patient a copy must be kept with the patient’s notes.
• Record only known facts – do not record opinions.
• Where death, serious injury or serious incident (including a near miss that could have resulted in a serious outcome) has occurred, follow the serious incident procedure.
• This incident and/or risk assessment form must be completed within 2 working days of the incident.

Part 1 – Incident Form

Incident Details:	Place & exact location of incident:
Date of incident:   Time of incident:
Description of Incident: (Tick box)
Accidental InjurySelf HarmClinical risk due to mental ill healthClinical waste or sharps incidentDrug ErrorEquipment failureFireDisease	Loss or damage to propertyUnexpected Student deathViolent incidentVulnerable child/ adult incidentWork related ill healthNear missOther (please state)

Details of incident (continue on separate sheet if necessary)

Who was affected by the incident?  (Tick box)
Ayurva employee and/or Volunteer?		If yes, name, job title and base of employee:
Student (please give name, address of Student):
Visitor	Trainee/student		Contractor
Public	Other   –   give details:
Details of any other organisations involved:

Did any person suffer injury or ill health?	Yes		No
If yes, what was the injury or ill health and to what part of the body?
If a member of staff – were they able to continue working? If no – how long were they absent for?		Yes		No

Details of any witnesses to the incident.
Name: Title: Base:			Name: Title: Base:
Office use only                                                               Is this incident reportable?
HSE/RIDDOR	Police			CFSMS		NPSA
Other (please state)
Date reported:
Further investigation required?		Yes			No

Part 2 – Risk Assessment Form

If the risk assessment relates to a potential problem, rather than an incident that has occurred, please complete the following details where appropriate:
Location:   Department:   No of staff:	Student Name:   Telephone:   Address:

Please complete the following sections for Incident Reports and Risk Assessments

Job/ Task/ Activity
Hazard
Who is at risk?
Consequences/ Severity			Risk Score (i.e. multiplied) =
Probability/ Likelihood
What are the existing control measures?
Are they adequate?	Yes			No
New Control Measures
Financial/ other resource implications
Review Date
Revised risk score following review

Contact details:
Person completing Parts 1 & 2 of form   Name:   Title:   Phone number:   Signature:   Date:	Manager/Senior staff who was reported to   Name:   Title:   Phone number:   Signature:   Date: