BARNSLEY CLINICAL COMMISSIONING GROUP INCIDENT REPORTING AND MANAGEMENT POLICY

Version:	0.3 9 (updated July 2021)
Approved By:	Governing Body
Date Approved:	October 2019 – Audit Committee 16 September 2021 – Audit Committee
Name of originator / author:	Richard Walker – Head of Governance & Assurance Kay Morgan - Governance & Assurance Manager
Name of responsible committee/ individual:	Governing Body (Approval) Audit Committee (review)
Name of executive lead:	Chris Edwards
Date issued:	September 2021
Review Date:	3 years from approval
Target Audience:	Barnsley CCG staff

Amendment Log

Version No	Type of Change	Date	Description of change
V 0.1	Draft	June 2017	New Policy
V 0.2	Two yearly review	June 2019	Minor amendments
V0.3	Minor Update	July 2021	Minor Update Removal of reference to web based incident form Updated incident / risk assessment matrix inline with HSE risk assessment matrix

CONTENTS

Ref	Title	Page
1.	Introduction	4
2.	Scope	4
3.	Purpose & Aim	4
4.	The Risks of not having this Policy in place	5
5.	Definitions	5
6.	Principles	5
7.	Roles and Responsibilities	5
8.	Procedure	7
9.	Monitoring the Compliance and Effectiveness of this Policy	8
10.	References	8
11.	Links to other CCG Policies and procedures	9
12.	Review of this Policy	9

APPENDICES

Appendix	Title	Page
Appendix 1	Incident Flow Chart Including Summary of responsibilities for Incident Reporting	10
Appendix 2	Incident Reporting, Investigation and Sign-off Responsibilities.	11
Appendix 3	Incident Report Form	12
Appendix 4	Incident Investigation Form	14
Appendix 5	Definitions	16
Appendix 6	References	18
Appendix 7	Guidance – How to conduct an investigation	19
Appendix 8	Equality Impact Assessment	24

BARNSLEY CLINICAL COMMISSIONING GROUP INCIDENT MANAGEMENT POLICY
1.	INTRODUCTION
NHS Barnsley Clinical Commissioning Group (CCG) places high value on the importance of establishing a safety, reporting and learning culture within the organisation. Effective incident reporting and management is one of the fundamental tools of risk management, the aim of which is to collect information about incidents, including near misses, ill health and hazards, which will help to facilitate wider organisational learning and minimise recurrence
1.1	To support this, the CCG has developed a culture to ensure that risk management is an integral part of everything we do as defined within the CCGs Integrated Risk Management Framework. The Integrated Risk Management Framework defines the systematic assessment of all risks the organisation faces.
1.2	The CCG promotes an open and fair approach to incident reporting, management and investigation for both staff and the public. The CCG wishes to foster an environment where staff and the public are encouraged to report incidents and near misses.
1.3	It is good practice for all organisations to record and learn from all Incidents and some categories of incidents have to be reported by law. This involves monitoring and investigating of the immediate and underlying causes of incidents and accidents to staff, visitors and the public, reporting the findings and learning from them to minimise recurrence. The CCG will take all reasonable practicable corrective action to ensure the health, safety and wellbeing of its employees, public, contractors and any other persons affected by its services.
1.4	The CCG has a common reporting system, and a centrally maintained database for incidents. Reporting of all incidents and near misses, regardless of severity, is mandatory.
2.	SCOPE
This Policy applies to ‘corporate’ incidents i.e. those occurring in CCG premises or affecting staff engaged on CCG business. Incidents relating to clinical services commissioned by the CCG are managed by the relevant provider, any meeting the threshold of a Serious Incident are reported on the national database STEIS and the resulting investigation quality assured by the CCG as per our the Serious Incidents Policy.
3.	PURPOSE & AIM
The purpose of this document is to provide guidance to all CCG Staff in relation to the reporting and management of incidents. The CCG encourages all staff to report all incidents, accidents and near misses in order to ensure compliance with statutory and regulatory reporting requirements
3.1	The aim of this policy is to ensure that the organisation captures all incidents and near misses, learns and shares lessons from them to reduce the chance of a similar incident happening again and takes appropriate action to protect staff, contractors, volunteers and members of the public from harm
4.	THE RISKS OF NOT HAVING THIS POLICY IN PLACE
4.1	If this Policy is not in place and implemented, the CCG: May not meet its statutory obligations. Will not have an early warning system in relation to safety and quality May fail to share learning across the organisation Will be inhibited in fostering a culture of openness May undermine the CCGs Risk Management Framework, Fire Policy and Health and Safety Policy May fail to recognise the equality, diversity, values and human rights of people May suffer reputational harm. May suffer financial harm
5.	DEFINITIONS
5.1	For the purposes of this Policy an incident is any incident/accident or near miss, which had, or may have had the potential to cause harm, dissatisfaction or injury to persons, or cause Loss or damage to property i.e result in an adverse outcome. This definition includes hazards, accidents, ill health, dangerous occurrences and near misses. Appendix 5 provides a list and description of the meaning of the terms used in the context of the policy or procedure.
6.	PRINCIPLES
6.1	In accordance with the law and accepted good practice it is CCG policy to ensure all incidents are reported and investigated. To ensure effective incident reporting and investigating procedures are followed in the CCG and that external organisations are informed of incidents as required. To promote a culture which encourages individuals to report incidents and near misses and to learn from incidents To ensure that risks are managed effectively including investigation and that the organisation has in place robust systems of risk assessment and monitoring processes for incidents,
7.	ROLES AND RESPONSIBILITIES
7.1	This section outlines the roles and responsibilities of individuals, departments and committees with regard to Incident Reporting and Management. The Chief Officer – Has overall accountability for incident management within the CCG, including establishing and maintaining an effective risk management system within the organisation, compliance with the Health and Safety at Work Act, sharing lessons learnt and ensuring that this Policy is effectively communicated to all staff. This is formally delegated at follows:
7.1.1	Chief Nurse – Leading the development of appropriate systems and processes to manage clinical serious incidents in line with the CCGs responsibilities and Serious Incident Policy. The Chief Nurse is the Caldicott Guardian for the CCG
7.1.2	Head of Governance and Assurance – Development and implementation of arrangements for non-clinical incident management and ensuring that reports are completed and sent to external agencies as appropriate. This is the Senior Information Risk Owner (SIRO) for the CCG.
7.1.3	Governance & Assurance Manager – Responsible for the day to day coordination of incident management and investigation. Also responsible for logging, maintenance and extracting information from the incident database and provision of relevant monitoring reports.
7.1.4	Managers - are responsible for ensuring that: all incidents (including serious incidents), which occur in their areas of responsibility, are reported immediately and investigated staff at all levels understand the need to report all incidents, accidents and near misses as per this policy and procedure and to ensure compliance with the CCG’s legal obligations staff affected by an incident receive the necessary support and counselling (if required).
7.1.5	CCG Staff Members – Have a responsibility for being mindful of any adverse incident and report to their line manager as soon as is reasonably practicable.
7.1.6	CCG Committees The Health & Safety Group – will receive and review a report on all Fire Health & Safety Incidents at each meeting of the Committee The Information Governance Group – will receive and review a report on all Information Governance Incidents at each meeting of the Committee The Audit Committee – will receive and review an annual report of all CCG reported incidents
8.	PROCEDURE
8.1	The following procedure specifies the action to be taken in the event of an incident / accident. A flow chart at Appendix 1 documents the procedure.
8.1.1	In the event of an incident immediate action should be taken to ensure the health needs of the individuals affected are dealt with. Should any situation pose imminent danger to others, attempts should be made to reduce the risk to the environment, staff and the public.
8.1.2	Should the initial assessment deem the incident to be serious (as detailed in section 2) the Chief Nurse or Deputy Chief Nurse (for clinical incidents) or other appropriate senior manager (for non-clinical incidents) should be alerted immediately.
8.1.3	Consideration should be given to any immediate notification of the incident to external agencies (such as police, H&S Executive, NHS Digital, Information Commissioners Office) where appropriate and on advice from the Head of Governance and Assurance or Governance and Assurance Manager.
8.1.4	The Incident Report Form (Appendix 2) should be completed by the member of staff involved in the incident (or if unable to do so by their line manager) as soon as reasonably practical wherever possible within 24 hours.
8.1.5	Completed Incident forms will be reviewed by the Head of Governance & Assurance or deputy (within timescales as detailed in appendix 7 – How to Conduct an Investigation) who will: Undertake an initial review, risk assessment and grading of the incident referring to the Integrated Risk Management Framework & Risk Assessment matrix at Appendix 7 If the incident is deemed serious or has potential to be a serious incident inform the Chief Nurse (for clinical incidents) or other appropriate senior manager (for non-clinical incidents) immediately Ensure that external agencies are informed as required i.e. RIDDOR Reporting, Information Commissioners Officer, NHS Digital. Determine if any other initial actions are required and there is any early learning for dissemination. Arrange for the incident to be logged on the CCGs Register of Incidents Request the appropriate Head of Department / Manager / specialist Advisor to undertake an investigation.
8.1.6	The appropriate Head of Department / Manager / specialist advisor will: Undertake an investigation into the incident and complete Incident Investigation Form, seeking advice and support from the relevant expert advisor where appropriate. For timescales to complete the incident investigation refer to appendix 7 – Guidance – How to conduct an investigation Will feed back the learning from the incident to the staff member reporting the incident
8.1.7	The Head of Governance & Assurance or relevant executive lead (assisted by specialist advisor and Governance and Assurance Manager where appropriate) will: Review the investigation form requesting further clarity / information as required Sign off the investigation form and return it to the Corporate Affairs Team to be retained with original incident report form Disseminate any learning from the investigation
8.1.8	The Corporate Affairs Team will update the Incidents database.
8.1.9	The Governance and Assurance Manager will: Produce incident monitoring trends reports for submission to the Health & Safety Group, Information Governance Group and Audit Committee as appropriate. Produce a report of the lessons learned from incident and disseminate to staff.
9.	MONITORING THE COMPLIANCE AND EFFECTIVENESS OF THIS POLICY
9.1	The CCG’s performance in the management of incidents will be monitored by qualitative and quantitative indicators as detailed below through regular reports to the Health and Safety Group, Information Governance Group and Audit Committee: Quantitative The number of incident reports completed Qualitative Actions taken Recommendations made Sharing of learning An Annual Report of Incidents will also be produced by the Governance and Assurance Manager.
10.	REFERENCES
Appendix 5 provides a list of the legislation, guidance and best practice that has been taken into consideration in the development of this policy and procedure:
11.	LINKS TO OTHER CCG POLICIES AND PROCEDURES
This Policy links to: Risk Management Framework Health and Safety Policy Fire Safety Policy Security Policy Fraud, Bribery & Corruption Policy Serious Incident Policy Information Security Policy Information Governance Incident Reporting Procedure
12.	REVIEW OF THE POLICY
This Policy will be reviewed 3 years form the date of approval. However the Policy may need earlier revision should there be a new requirement to meet statutory mandatory or good practice standards.

APPENDIX 1

INCIDENT REPORTING FLOW CHART

Make scene safe Prevent reoccurrence Attend to injured parties Incident Occurs

Any immediate notification to external agencies: Police, Health & Safety Executive, Fire Authority If initial assessment of the incident is or has potential to be a serious incident. Alert Chief Nurse immediately for clinical incidents and appropriate senior manager for non-clinical incidents

Complete incident report form or Telephone with details of incident to Corporate Affairs Team

Arrange for Incident Report to External Agencies if required Incident form reviewed by Head of Governance and Assurance or Governance & Assurance Manager

Alert Deputy Chief Nurse Assess if deemed serious incident

Assign to appropriate investigating officer to complete Incident Investigation form

Incident logged on CCG Incident Register

Return signed form to Corporate Affairs Team to update the incident data base

APPENDIX 2

Type	Responsibilities	Possible onward reporting route
Reporting of incident	Investigating incident (non serious)	Expert advisor & investigator where serious	Sign off
Accident or injury	All incidents would normally be reported by the person directly involved, or where incapacitated another witness to the incident.	Line manager / Head of Service of the person reporting the incident or Expert Advisor where appropriate	Health & Safety Manager	Head of Governance & Assurance	RIDDOR (HSE) (if reportable)
Estates, facilities, security	Health & Safety Manager	Head of Governance & Assurance
Verbal or physical abuse	Health & Safety Manager or HR Business Partner	Chief Officer	HR Business Partner if other policies need to be invoked
Information Governance (eg breach of confidentiality)	IG Manager (eMBED) / CCG IG Lead	Chief Nurse (Caldicott Guardian) or SIRO (Head of Governance & Assurance)	NHS Digital Incident Reporting Tool (see guidance)
Information Security (eg loss of hardware or data)	IG Manager (eMBED) / CCG IG Lead	SIRO (Head of Governance & Assurance
Cyber Security (eg hacking, phishing)	IT Help Desk / IT Service Delivery Manager (eMBED)
Financial loss	Local Counter Fraud Specialist (if fraud, Computer Misuse or DPA 2018 breach suspected)	Chief Finance Officer	Local Counter Fraud Specialist or NHS Counter Fraud Authority https://cfa.nhs.uk/reportfraud (if fraud, Computer Misuse or DPA 2018 breach suspected)
Quality or patient safety	CHC Service Lead / Head of Meds Optimisation as appropriate	Chief Nurse / Deputy Chief Nurse / Medical Director (as appropriate)	Refer to Serious Incident Policy
Safeguarding	Designated Nurses	Chief Nurse	As advised by Designated Nurse within definitions stated in the Care Act 2014 and BSAB policies and procedures

APPENDIX 3

NHS BARNSLEY CCG

INCIDENT REPORTING FORM (IR1)

Incident reporter details
Name:
Job Title:
Date reported:
Incident description
What happened? Describe the incident. (please record facts only, not opinion)
When did the incident happen? (please enter date and time if known)
Where did the incident happen? (describe the location)
Who was involved in the incident and who witnessed the incident?
Were there any adverse effects arising from the incident? Record type of injuries & first aid given (& by whom) / declined . Financial costs, loss of service, reputational impact etc
Post-incident actions
What actions were taken immediately after the incident? (to make area safe/ prevent reoccurrence / preserve the scene)
Are any further actions planned?
Incident type (mark only 1 box)	Type of incident (Tick)	Incident Investigating Officer (non serious)	Possible Onward reporting
Accident / Injury	Line Manager /Head of Service of the person reporting the incident	RIDDOR: Health & Safety Executive (if reportable) by investigating officer
Estates / Facilities / Security
Verbal or physical abuse	HR Business Partner if other policies need to be invoked
Information Governance (eg breach of Confidentiality)	NHS Digital Incident Reporting Tool (see guidance)
Information Security (eg loss of hardware or data)
Cyber security (eg hacking, phishing)
Financial Loss	Local Counter Fraud Specialist or NHS Counter Fraud Authority (if fraud, Computer Misuse or DPA 2018 breach suspected)
Quality or patient safety	Refer to Serious Incident Policy
Near Miss
Other
Do you want to tell us anything else? (factual information only not to include opinions)

Please return the completed form as soon as possible after the incident to:

Corporate Affairs Team, Room 49, Hillder House, 49/51 Gawber Road Barnsley S75 2PY

Or by email to Governance & Assurance Manager kay.morgan2@nhs.net in subject line quote ‘ IR1 and date’

Corporate Affairs team - Office use only
Date received
Logged on Incident Register
Incident Reference

APPENDIX 4

IR2 INCIDENT INVESTIGATION REPORT
Incident Ref.	Investigating Officer: Name (print)	Job Title
Type of Incident	Incident Grade (refer appendix 7 of Incident Reporting & management Policy)
Brief Details of Incident
Format of investigation
Facts ascertained from the investigation (contributory factors which may have played a part in the incident conditions / staffing numbers / illness / lack of procedure etc (was the injured party in hospital for more than 24 hours / off work for 5 days or more
Any further action undertaken or required as a result of the incident
Lessons learnt (and disseminated where appropriate)
Expert Advice Sought?
Comments – Reviewing Officer (to record any comments by Officer reviewing Investigation Form)
Investigation Form Reviewed and signed off by	PRINT NAME	SIGNATURE
JOB TITLE	DATE

NB: Use additional sheets of paper if required to record investigation

Retention periods Incident report and Investigation Forms

10 years (not serious)

20 years (serious)

All forms & associated correspondence stored centrally by the Corporate Affairs Team

APPENDIX 5

DEFINITIONS

Term	Definition
Dangerous Occurrence	This is a ‘near miss’ which could have led to serious injury or loss of life. Dangerous occurrences are defined in the Reporting of Injuries Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) and are always reportable to the enforcement authorities. Examples include the collapse of a scaffold or the failure of any passenger carrying equipment.
Harm	Physical or mental injury.
Hazzard	Is the potential of a substance, person, activity or process to cause harm, ill health and injury; damage to property, plant, products or the environment, production losses or increased liabilities, Hazards take many forms including, for example, chemicals, electricity and working at your desk.
Incident	An incident is any incident/accident, near miss or untoward event, which had or may have had the potential to cause harm, dissatisfaction or injury to persons, loss or damage to property i.e. result in adverse outcome. This definition includes hazards, accidents, ill health, dangerous occurrences and near misses.
Information Governance Serious Incident	Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals should be considered as serious.
Investigation	The act or process of investigating, careful search or examination in order to discover the root cause of the incident / accident
Near Miss	A near miss is an incident that did not actually lead to harm, loss or damage, but had potential to. The CCG encourages the reporting of a ‘near miss’ as this may identify any changes in procedures, processes and systems which are required to prevent further events from causing actual harm, loss or damage.
Policy	A deliberate plan of action adopted or pursued by an individual organisation to guide decisions and achieve rational outcomes. A policy is a statement of intent, describing the approach or course of action the organisation is taking in respect of a particular issue. Policies are underpinned by relevant evidence based procedures and guidelines and enable management and staff to make correct decisions, work effectively and comply with relevant legislation and organisational aims and objectives.
Procedure	A set of step-by-step instructions that describe the appropriate method for carrying out tasks or activities to achieve the highest standard possible and to ensure efficiency, consistency and safety.
RIDDOR	Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.
Risk	Is the likelihood of a substance, activity or process to cause harm. A risk can reduce the hazard controlled by good management.
Serious Incident	The principle definition of a Serious Incident is defined by the National Patient Safety Agency as: Unexpected or avoidable death of one or more patients, staff, visitors or members of the public; Serious harm to one or more patients, staff, visitors or members of the public or when 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 health care 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 for the organisation or the wider NHS; One of the core set of ‘Never Events’ as updated by the NHS England on an annual basis.

APPENDIX 6

REFERENCES

This is a list of the legislation, guidance and best practice that has been taken

into consideration in the development of this policy and

procedure:

The following legislation

Health and Safety at Work Act 2017

The Management of Health & Safety at Work Regulations 1999

Mental Health Act 1983 and 2007

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013

Human Rights Act 1998

Data Protection Act 1998

General Data Protection Regulation 2018

The Children Act 2004

Mental Capacity Act 2005

The following guidance has been used in the development of this policy

and procedure:

An Organisation with a Memory – DOH 2000

Doing Less Harm – DOH and NPSA 2001

Seven Steps to Patient Safety – NPSA

Building a Safer NHS for patients – Implementing An Organisation with a Memory – DOH 2001

Safety First: A report for patients, clinicians and healthcare managers – DOH 2006

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013(RIDDOR)

Information Commissioner Guidance Documents.

Health and Safety Executive (HSE) Reporting – www.hse.gov.uk

Local Security Management Specialist - Physical assault reporting

NHS Estates – Reporting fire related incidents

NHS Litigation Authority (NHSLA) Requirements

The Private and Voluntary Health Care (England) Regulations 2001

Statutory Notifications Guidance HCC) 2006

Working together to Safeguard Children 2015

No Secrets – Guidance on developing and implementing multi-agency procedures to protect vulnerable adults from abuse

Francis Report – report of the Mid Staffordshire NHS Foundation Trust 2013.

Health and Safety Executive ‘investigation of Accidents and Incidents’ A workbook for employees, unions, safety representatives and safety professionals

APPENDIX 7

HOW TO CONDUCT AN INVESTIGATION

It is essential that all incidents are investigated promptly. The prime objectives of an

investigation are to:

Determine the sequence of events leading to the incident – A timeline of events & maintain records.

Discussions & interviews with all relevant parties – maintain notes of discussion

Determine what was managed well

Establish the unsafe systems of working, procedures, policies, acts and/or unsafe conditions within the sequence of events that contributed to the incident.

Determine the human, organisational and or job factors that give rise to the unsafe acts.

Initiate short-term action to eliminate the immediate causes of the incident

Establish a longer-term programme to correct and manage the underlying human, organisational and job factors, and hence prevent a reoccurrence of the same or similar incident or near miss.

It is unrealistic to suggest that all incidents should be analysed/investigated to the same degree or at the same level. The depth of investigation and analysis required for individual incidents is dependent upon a risk assessment

The responsibility for an Incident risk assessment rests with the person completing the investigation.

The outcome of the Risk Assessment ie risk rating will be recorded on the Incident Investigation Form

Risk Rating	Priority Description/Action
15-25 Extreme Red	Prohibit. Investigate in line with Serious Incident Procedure. Investigation Officer to be established. Root Cause Analysis to be carried out. Full Investigation Report required within 3 months of incident
8-12 High Risk Amber	High Priority: Analyse at service level Undertake Root Cause Analysis. ‘Responsible Person’ to lead. Record results on Incident Investigation form within 1 month of incident
4-6 Moderate Risk Yellow	Medium Priority: Analyse at local level. ‘Responsible Person’ to lead Analyse and review within 5 working days. Record results on Incident form
1-3 Low Risk Green	Low Priority: Review at local level. ‘Responsible Person’ to lead. Review within 5 working days. Record results on Incident form. Analyse in more detail if deemed useful.

Step 1 – Risk Assessment

As determined in the CCGs Integrated Risk Management Framework

Table 1

Consequence score (severity levels) and examples of descriptors
1	2	3	4	5
Domains	Negligible	Minor	Moderate	Major	Catastrophic
1. Adverse publicity/ reputation	Rumours Potential for public concern	Local media coverage Short-term reduction in public confidence	Local media coverage Long-term reduction in public confidence	National media coverage Service well below reasonable public expectation	National media coverage Service well below reasonable public expectation. Total loss of public confidence
2. Business objectives/ projects	Insignificant cost increase/ schedule slippage	<5 per cent over project budget Schedule slippage	5–10 per cent over project budget Schedule slippage	10–25 per cent over project budget Schedule slippage Key objectives not met	>25 per cent over project budget Schedule slippage Key objectives not met
3. Finance including claims	Small loss Risk of claim remote	Loss of 0.1–0.25 per cent of budget Claim less than £10,000	Loss of 0.25–0.5 per cent of budget Claim(s) between £10,000 and £100,000	Loss of 0.5–1.0 per cent of budget Claim(s) between £100,000 and £1 million	Loss of >1 per cent of budget (£3.8m) Claim(s) >£1 million
4. Human resources / organisational development / staffing / competence	Short-term low staffing level that temporarily reduces service quality (< 1 day)	Low staffing level that reduces the service quality	Late delivery of key objective / service due to lack of staff Unsafe staffing level or competence (>1 day) Low staff morale	Uncertain delivery of key objective/service due to lack of staff Unsafe staffing level or competence (>5 days) Very low staff morale Loss of key staff	Non-delivery of key objective/service due to lack of staff Ongoing unsafe staffing levels or competence Loss of several key staff
5. Impact on the safety of patients, staff or public (physical/psychological harm)	Minimal injury requiring no/minimal intervention or treatment	Minor injury or illness, requiring minor intervention	Moderate injury requiring professional intervention	Major injury leading to long-term incapacity/disability Mismanagement of patient care with long-term effects	Incident leading to death Multiple permanent injuries or irreversible health effects An event which impacts on a large number of patients
6. Quality / complaints / audit	Peripheral element of treatment or service suboptimal Informal complaint / inquiry	Overall treatment or service suboptimal Single failure to meet internal standards Minor implications for patient safety if unresolved Formal complaint (stage 1)	Treatment or service has significantly reduced effectiveness Repeated failure to meet internal standards Major patient safety implications if findings are not acted on Formal complaint (stage 2) complaint	Non-compliance with national standards Low performance rating; Critical report Significant risk to patients if unresolved Multiple complaints/ independent review	Totally unacceptable level or quality of treatment/service; Gross failure to meet national standards Inquest / ombudsman inquiry Gross failure of patient safety if findings not acted on
7. Service / business interruption Environmental impact	Loss/interruption of >1 hour Minimal or no impact on the environment	Loss/interruption of >8 hours Minor impact on environment	Loss/interruption of >1 day Moderate impact on environment	Loss/interruption of >1 week Major impact on environment	Permanent loss of service or facility Catastrophic impact on environment
8. Statutory duty/ inspections	No or minimal impact or breach of guidance/ statutory duty	Breach of statutory legislation Reduced performance rating if unresolved	Single breach in statutory duty Challenging external recommendations/ improvement notice	Multiple breaches in statutory duty Enforcement action Improvement notices Low performance rating Critical report	Multiple breaches in statutory duty Prosecution Complete systems change required Zero performance rating Severely critical report

Table 2 Likelihood score (L)

Likelihood score	1	2	3	4	5
Descriptor	Rare	Unlikely	Possible	Likely	Almost certain
Frequency How often might it/does it happen	This will probably never happen/recur (Less than once a year)	Do not expect it to happen/recur but it is possible it may do so (Once a year)	Might happen or recur occasionally (Monthly)	Will probably happen/recur but it is not a persisting issue	Will undoubtedly happen / recur,possibly frequently (Daily)

Table 3 Risk scoring = consequence x likelihood ( C x L )

Likelihood
Likelihood score	1	2	3	4	5
Rare	Unlikely	Possible	Likely	Almost certain
5 Catastrophic	5	10	15	20	25
4 Major	4	8	12	16	20
3 Moderate	3	6	9	12	15
2 Minor	2	4	6	8	10
1 Negligible	1	2	3	4	5

For grading risk, the scores obtained from the risk matrix are assigned grades as follows

1 - 3	Low risk
4 - 6	Moderate risk
8 - 12	High risk
15 - 25	Extreme risk

Instructions for use

1	Define the risk(s) explicitly in terms of the adverse consequence(s) that might arise from the risk.

2	Use table 1 to determine the consequence score(s) (C) for the potential adverse outcome(s) relevant to the risk being evaluated.

3	Use table 2 (above) to determine the likelihood score(s) (L) for those adverse outcomes. If possible, score the likelihood by assigning a predicted frequency of occurrence of the adverse outcome. If this is not possible, assign a probability to the adverse outcome occurring within a given time frame, such as the lifetime of a project or a patient care episode. If it is not possible to determine a numerical probability then use the probability descriptions to determine the most appropriate score.

4 Calculate the risk score the risk multiplying the consequence by the likelihood: C (consequence) x L (likelihood) = R (risk score)

5	Identify the level at which the risk will be managed (table 3) in the organisation, assign priorities for remedial action, and determine whether risks are to be accepted on the basis of the colour bandings and risk ratings, and the organisation’s risk management system. Include the risk in the organisation risk register at the appropriate level.

Step 2 - Level of Analysis/Investigation Required

The level of analysis/investigation is dependent on the Risk Rating obtained from Risk Assessment of the Incident.

Green Incidents - Low Risk (Risk Score 1-3) and Yellow Incidents – Moderate Risk (Risk Score 4 - 6)

Low and moderate risk Incidents should be reviewed at a local level by the department in which the incident occurred. It is important to identify, record and action any learning points and safety improvement measures identified as a result of the incident review.

Where the necessary improvements are not within the control of the department, the local manager is responsible for ensuring that the identified findings are appropriately communicated to the relevant Officer for consideration.

The investigation should be completed within 5 working days of the incident occurring and documented on the Incident Report Form The responsibility to follow up the action plan lies with the local team.

Amber Incidents – High Risk (Risk Score 8 - 12)

High Risk Incidents will be subject to modified Root Cause Analysis.

It is the responsibility of the relevant manager and Head of Governance and Assurance to ensure that all the learning points and safety improvements are appropriately identified and implemented within the department and organisation where appropriate.

The analysis and review of this category of incident should be completed within 1 month of the incident occurring. (with an initial investigation completed within 5 days – the HSE require reportable incidents to be reported within 15 days for over 7 day incidents).

The results of the incident review should be recorded on the Incident Report Form attached additional information if required.

Red Incidents – Extreme - Serious Incidents

Where a serious incident occurs immediately notify a member of the senior management Team (identified below). The senior Management Team will make decision about onward reporting and investigation of the incident taking into account Appendix 2 ‘Incident Reporting, Investigation and Sign Off responsibilities’

Chief Officer

Chief Finance Officer

Chief Nurse

Director of Commissioning

Director of Performance and Strategic Planning

Head of Governance and Assurance

Head of Communications

Head of Medicines Management

For all red extreme incidents an investigating officer will be appointed to lead the investigation process and act as the contact and coordination point for all matters relating to the investigation. The Investigating Officer will be trained in root cause analysis techniques.

Investigations Reports with action plans must be completed within 12 weeks of the incident occurring. (with an initial investigation completed within 5 days - the HSE require reportable incidents to be reported within 15 days for over 7 day incidents). In cases of a reportable death, specified injury or dangerous occurrence, the HSE must be informed within 10 days of the incident.

All risks identified should be considered for inclusion on the Corporate Risk Register.

Examples of Extreme Serious Incidents could include:

Safeguarding incidents meeting the definition

Death or serious injury to a member of staff in the course of their NHS duties

Serious fires or other serious damage which occurs on NHS premises. Of particular concern would be any fire which resulted in casualties or major disruption to services

Serious or unexplained outbreaks of infection or disease in hospital or the wider community including care home (e.g. food poisoning, Legionnaire’s Disease) or the confirmed transmission of serious infections disease between an NHS staff member and a patient (e.g HIV/Hepatitis B)

Major system failure

Major service disruption e.g. due to power failure or flooding.

Major breach of patient confidentiality (refer also to the CCG’s Procedure for Handling Information Governance Incidents and Health and Social Care Information Centre (hscic) Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incident Requiring Investigation)

Any incident involving the actual or potential loss of personal information that could lead to identity fraud or have other significant impact on individuals. (refer also to the CCG’s Procedure for Handling Information Governance Incidents and Social Care Information Centre (hscic) Checklist Guidance for Reporting, Managing and Investigating Information Governance and Cyber Security Serious Incident Requiring Investigation)

Incidents/concerns regarding the actions of NHS staff, examples include fraudulent behaviour, gross misconduct. This could lead to suspension/summary dismissal, media interest and involvement of the criminal justice system.

A pattern emerging that is causing concern such as a high number of complaints regarding a member of staff, a particular service and/or hospital /care home that may warrant further investigation and action.

APPENDIX 8

Equality Impact Assessment

Title of policy or service:	Incident Reporting and Management Policy
Name and role of officer/s completing the assessment:	Paige Dawson, Kay Morgan and Richard Walker
Date of assessment:	25 July 2019 and 5 August 2021
Type of EIA completed:	Initial EIA ‘Screening’ ☐ or ‘Full’ EIA process ☒

1. Outline
Give a brief summary of your policy or service including partners, national or regional	Policy to provide a process and framework to manage incidents occurring within the CCG. The aim of the policy is to comply with statutory requirements, legislation and best practice.
What Outcomes do you want to achieve	that the organisation captures all incidents and near misses, learns and shares lessons from them to reduce the chance of a similar incident happening again and takes appropriate action to protect staff, contractors, volunteers and members of the public from harm
Give details of evidence, data or research used to inform the analysis of impact	Substantial guidance was used in the creation of this policy and is listed in the body of the policy.As a result no adverse impact was found for any protected group.
Give details of all consultation and engagement activities used to inform the analysis of impact

Identifying impact:

Positive Impact:	will actively promote the standards and values of the CCG.

Neutral Impact:	where there are no notable consequences for any group;

Negative Impact:	negative or adverse impact: causes or fails to mitigate unacceptable behaviour. If such an impact is identified, the EIA should ensure, that as far as possible, it is eliminated, minimised or counter balanced by other measures. This may result in a ‘full’ EIA process.

2. Gathering of Information This is the core of the analysis; what information do you have that might impact on protected groups, with consideration of the General Equality Duty.
(Please complete each area)	What key impact have you identified?	For impact identified (either positive or negative) give details below:
Positive Impact	Neutral impact	Negative impact	How does this impact and what action, if any, do you need to take to address these issues?	What difference will this make?
Human rights	☐	☒	☐
Age	☐	☒	☐
Carers	☐	☒	☐
Disability	☐	☒	☐
Sex	☐	☒	☐
Race	☐	☒	☐
Religion or belief	☐	☒	☐
Sexual orientation	☐	☒	☐
Gender reassignment	☐	☒	☐
Pregnancy and maternity	☐	☒	☐
Marriage and civil partnership (only eliminating discrimination)	☐	☒	☐
Other relevant groups	☐	☐	☐
HR Policies only:	☐	☐	☐

IMPORTANT NOTE: If any of the above results in ‘negative’ impact, a ‘full’ EIA which covers a more in depth analysis on areas/groups impacted must be considered and may need to be carried out.

Having detailed the actions you need to take please transfer them to the action plan below.

3. Action plan
Issues/impact identified	Actions required	How will you measure impact/progress	Timescale	Officer responsible
No anticipated detrimental impact has been identified on any equality group. The policy is applicable to all employees and adheres to the, CCG statutory requirements to report incidents and best practice and makes all reasonable provision to ensure equity of access to all.	There are no statements, conditions or requirements that disadvantage any particular group of people with a protected characteristic – therefore there is no required action identified.	Richard Walker

4. Monitoring, Review and Publication
When will the proposal be reviewed and by whom?	Lead / Reviewing Officer:	Date of next Review:

Once completed, this form must be emailed to the Equality Lead barnsleyccg.equality@nhs.net for sign off:

Equality Lead signature: Date:	17/12/19