ADULTS’ HEALTH & CARE DEPARTMENT No 03/17

SERIOUS INCIDENT POLICYVersion 2

Effective date August 2017

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 Manageror Karen Alexander, Strategic Service Manager, Safeguarding, Quality and Governance Team.

Signed

Designation

Date

Jo Lappin

Head of Safeguarding and Governance

18/10/17

2

3

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 GuidanceHealth and Social Care Act 2008 (Regulated Activities) Regulations 2014Learning, candour and accountability (December 2016) Care Quality CommissionPan Hampshire Safeguarding Adults Policy (May 2015)

HAMPSHIRE COUNTY COUNCIL AND ADULTS’ HEALTH & CARE DEPARTMENT REFERENCES

Duty of Candour PolicyDebrief Staff Support guidanceDeath of a Service User policy.

AUTHORITY TO VARY THE PROCEDURE

Care Governance BoardDepartmental Management Team

4

Contents

Section 1 – Purpose Page 5

Section 2 – Definition of Incidents Page 5

Section 3 – Incident reporting process Page 6

Section 4 – Duty of Candour Page 8

Section 5 – Types of review Page 8

Section 6 – Critical Incident Reviews – guiding principles Page 9

Section 7 – The CIR process and flowchart Page 10

Section 8 – Support for the reviewing process Page 14

Section 9 – Joint agency reviews Page 14

Section 10 – Multi-agency reviews and SARs Page 14

Section 11 – Gaining and embedding the learning Page 15

Section 12 – De-briefing Service Page 16

Section 13 – Parallel Process and statutory reviews Page 17

Appendix A – Immediate Action after a Critical Incident Page 20

Appendix B – Critical Incident Review template Page 21

Appendix C – CIR Action Plan format Page 22

Appendix D – Other types of reviews for serious incidents Page 22

5

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 to inform learning and changes that will reduce 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.

2. 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 & Care or 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).

6

3. 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 & Care incident 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 & Care should 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: http://intranet.hants.gov.uk/adult-services/as-health-safety/as-hs-forms.htm#incident 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 & Care should be reported to 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,

7

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 Team should be made for the attention of the S,Q & G Team Strategic Service Manager by telephone or email at : safeguarding.admin@hants.gov.uk

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.

8

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.

4. 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.

9

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 will then make 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.

10

7. THE CRITICAL INCIDENT REVIEW PROCESS

The criteria for undertaking a critical incident reviewA critical incident is one where the service user is known to Adults’ Health & Care and 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 ReferenceThe 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.

11

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 Officer in 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.

CIR reviewers feedback the draft report to the front-line managers The CIR Reviewers will produce a written report which will be shared as a draft with the CIR commissioning Service Manager and Team Managers (this will occur at the 45 day stage) involved in the incident. This allows the front line managers to advise if there are any factual inaccuracies or gaps in understanding that they can assist with.

Service users and staff members’ names should be anonymised within the report. The report will be in a standard, agreed format (the template is found in appendix B). The CIR report will outline:

a pen picture of the service user(s) an overview of the incident informed by records and staff interviews the views of the service user and family members an analysis of what happened and why – in relation to practice and

systems issues, crystallised in the findings learning recommendations to improve practice and systems a chronology of key events (in the appendix).

N.B Where the findings involve specific learning for individual staff members, this aspect should be handled with sensitivity and consideration given to whether only a summary of the findings should be shared with the front line team.

Findings Workshop with the frontline team to develop the action planCIR reviewers (with support from the Learning and Review Manager) arrange a Findings Workshop with front line managers and teams, which should be undertaken if possible within the 60 day timeframe. The workshop (1.5 hours) allows the findings to be shared with front line staff and the development of a meaningful action plan which can be owned by the relevant front line staff.

12

Signing off the Reviewa) The Commissioning Operational Service Manager will share the report and action plan with their operational Head of Service andb) The Lead Reviewers will share the report and action plan with the Care Governance Working Group.

The Action PlanThe parties who have taken on actions from the Action Plan should undertake their actions over the next few months. Progress on implementation should be monitored by the commissioning Operational Head of Service and reported back to the Care Governance Board in 6 months time.

The plan is written and owned by the operational managers. The plan will have actions that are relevant to the frontline practitioners and local systems in order to achieve improvements in practice.

The action plan will: comprise operational level actions address problems or gaps in systems policy, procedures and / or practice clearly identify what needs to happen, who is responsible for the action

and the date by which it must be completed.

Reporting outcomes to the Care Governance BoardAt six months the CIR action plan with outcomes will be presented by the relevant operational Head of Service to the next Care Governance Board for discussion. The outcomes will be recorded by the Senior Incident Reporting Officer at Care Governance Board, to be added to the CIR database held by the Safeguarding, Quality and Governance Team.

13

CIR Process and Timeframes

14

8. SUPPORT FOR THE REVIEWING PROCESS

Two CIR Reviewers (from a pool of trained staff) will undertake the review. One of whom will have undertaken Root Cause Analysis training and they will take the lead. This group is largely made up of staff in the Safeguarding, Quality and Governance team, PaCT staff or Adults’ Health & Care Managers. The other Reviewer will usually either be experienced in undertaking reviews or will have operational experience and expertise that is directly relevant to the case being reviewed.

Lead Reviewers will be supported by a supervision session with the Learning and Review Manager to support initial planning. A further supervision session can be arranged later in the process to assist with the analysis and development of the findings if this is required. Lead Reviewers should refer to the Lead Reviewers Handbook which provides template letters and guidance in relation to the practical aspects of the undertaking the review, including the interviews with staff and meeting the family.

A Reviewers Network facilitated by the Learning and Review Manager will provide updates to reviewers on topics relevant to the reviewing task, and will arrange an annual Reviewers Network workshop where common issues and challenges can be discussed.

9. JOINT AGENCY REVIEWS

The nature of providing joined up services to adults in the community involves effective joint working across health and social care services. In many cases it will be important to liaise closely with health colleagues for their input into the review process, and to avoid duplication.

In some cases the nature of the involvement of health and social care agencies will indicate that both agencies need to take an active part in leading and participating in the review process. A joint agency review will use reviewers from both health and social care agencies. Where a joint agency review is indicated, the HCC Safeguarding, Quality and Governance Strategic Service Manager will gain agreement on a case by case basis with the relevant operational senior manager in HCC and the health trust.

A joint Terms of Reference would be developed with clear lines of accountability to the governance arrangements in both agencies.

10. MULTI-AGENCY REVIEWS AND SAFEGUARDING ADULTS REVIEWS

Where there has been a serious injury or unexpected death of a service user and there are concerns that this was connected to abuse or neglect and a number of local agencies have not worked together effectively to safeguard the individual, the statutory criteria for a Safeguarding Adults Review (SAR) may be met (Care Act section 44).

What to do if you are aware of a case that may meet the criteria for a SAR

15

Before making a SAR referral the person wishing to make the referral should have a conversation with the Adults’ Health & Care Learning and Review sub group representative (this is currently the Learning and Review Manager) to ensure that the Adults’ Health & Care representative knows about the case being put forward and is in agreement with the referral being made.

In order for a review to be considered by the HSAB Learning and Review group the concerns must relate to a person with needs of care and support – whether or not in receipt of services. In addition:

Abuse, neglect or acts of omission must be known or strongly suspected to have contributed to the harm caused.

There must also be concerns about systemic failings relating to multiple organisations and the potential to improve multi agency practice and partnership working.

A variety of reviews and audits can be facilitated under the HSAB Learning and Review Framework which can be found at www.hampshiresab.org.uk. Referral forms can be obtained from the HSAB website (above) and completed referral forms should be submitted to safeguarding.account@hants.gcsx.org.uk.

Where cases are found not to meet the SAR criteria but have a clear multi agency perspective where several agencies have played key roles in the case or circumstances prior to the incident, and valuable learning is indicated, the SAB may feel that it is appropriate to consider arranging a multi-agency workshop.

11. GAINING AND EMBEDDING LEARNING FROM SERIOUS INCIDENTS

Themed auditsOn some occasions a Records Review, Reflective Workshop or CIR will indicate the need for further specific information gathering around a particular issue which has been identified in the investigation. If this is the case, a themed audit may be undertaken by the Safeguarding, Quality and Governance Team to better understand a specific issue which may affect a number of service users county-wide. This may be in circumstances where a concern has been identified about a particular system or process and it is necessary to consider if the concern is generalised, rather than just specific to one team or locality. The audit will clarify the scale and risk of the issue, and inform management decisions to manage the risk.

Embedding the learning

16

As each incident is very different, a variety of methods will be used to make sure the learning from incidents moves out to frontline staff and teams. Methods used to disseminate learning could include:

one to one sessions with some staff where practice issues have come to light

discussions at team meetings or via the Team Briefings round table discussions with teams where the learning is particularly

relevant workshops designed for specialist teams or those fulfilling a specific role updating the social care practice manual in the light of lessons learned

12. THE DE-BRIEFING SERVICE

Sometimes service users are involved in unfortunate or traumatic events, and staff may witness, or be directly involved in some of these incidents. As a response to this there is a de-briefing service which all Adults’ Health & Care staff can access.

De-briefing is carried out by a trained support team made up from Adults’ Health & Care staff. The aim is to help staff to recognise and understand normal reactions to traumatic or extremely stressful events. De-briefing allows staff to think about their feelings and reactions with their immediate work colleagues. It also encourages the natural support that exists within teams that work together and encourages staff to seek help early.

Everyone reacts differently to traumatic events; however the following examples are typical situations which could generate a stress reaction in staff, and which may lead to a referral to the de-briefing service:

acts of actual or threatened violence against staff any incident which is particularly upsetting or emotionally charged injury or death to a staff member whilst at work any incident which overwhelms the normal coping mechanisms of staff any incident which attracts unusual and intensive media attention any incident which impacts on the mental health & wellbeing of staff involved.

Where a group of service users (as opposed to staff) within our in-house provider services have been impacted by a traumatic incident, the manager of the service may wish to contact the de-briefing service. Although a de-briefing session is unlikely to be appropriate for the service users, it may be possible for the de-briefing service to meet with staff in order to advise them about the kind of support that might be helpful for the service users.

Managers who think that their staff may benefit from a de-brief session should contact the service to discuss the situation, in order to see whether de-briefing is going to be appropriate. Debriefing works with groups of staff, not individuals and is not counselling (which can be accessed separately by staff through the usual channels). Referral forms for the debriefing service are available on the incident

17

reporting section of the downloadable forms and guidance area of the Health and Safety web pages: - Debriefing service information and referral form

If you would like to know more about the debriefing service you can email to the safeguarding.admin@hants.gov.uk and you will get a response to your email within 48 working hours.

13. PARALLEL PROCESSES AND OTHER STATUTORY REVIEWS

There may be parallel processes in place such as a criminal investigation or a coroner’s inquest which will need to be taken account of in terms of timing and the management of interviewing key staff. Any new areas of learning identified as a result of an inquest should be considered and reflected in a revised action plan following the inquest. This element can be referred to as the Part 2 CIR.

Some cases considered for review may overlap with statutory review processes such as domestic homicide review, mental health homicide review, Multi Agency Public Protection Arrangements (MAPPA) review or Children’s Serious Case Review. These statutory reviews will always take priority and the interface between the processes should be managed to dovetail activity as far as possible.

Where it is indicated that a statutory review is likely the internal CIR can form part of the documentation required.

HR Processes (e.g. capability or disciplinary processes)

HR processes are quite separate from a Critical Incident Review, and are guided by separate HCC policies. Information that is gained from practitioners during the process of a Critical Incident Review should remain confidential to that process unless the information suggests to the Lead Reviewer that a staff member’s practice falls outside the usual professional codes in which case the appropriate line manager should be advised by the Lead Reviewer.

Coroner’s inquests

The Department has a legal duty to assist the Coroner with his/her enquiries. The Coroner has a statutory right to request information in relation to cases s/he is investigating1, and to request that an officer of Hampshire County Council attend the inquest to present their evidence.

The purpose and remit of the inquest is to enable the Coroner to answer the following four questions:

- The identity of the deceased

- The place of death1 Coroners and Justice Act 2009 and Coroners (Inquest) Regulations 2013

18

- The time of death

- How the deceased came by his/her death.

Possible verdicts that can be found are: accident or misadventure, alcohol/drug related, industrial disease, lawful/unlawful killing, natural causes, open, road traffic collision, stillbirth or suicide. As an alternative, or in addition the coroner (or jury where applicable) may make a narrative conclusion.

Preventing future deaths – under Regulation 28 of the Coroners (inquests) regulations anything revealed by the investigation gives rise to a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and in the coroner’s opinion, action should be taken to prevent the occurrence or continuation of such circumstances, or to eliminate or reduce the risk of death created by such circumstances the coroner must report the matter to a person who the coroner believes may have power to take such action. The Coroner may require the Department to submit an action plan to show what steps are being taken to respond to the concerns raised..

Domestic Homicide Reviews

Domestic Homicide Reviews are carried out under section 9 of the Domestic Violence, Crime and Victims Act 2004 in circumstances where there has been a death of someone over 16 whose death has, or appears to have resulted from violence, abuse or neglect by:

(a) a person to whom he or she was related or with whom he or she was or had been in an intimate relationship

(b) a member of the same household as him or herself.

Children’s Serious Case Reviews

Serious Case Reviews concerning children are undertaken under Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 that requires Local Safeguarding Children Boards to undertake Safeguarding Children Serious Case Reviews where:

(a) abuse or neglect of a child is known or suspected AND(b) either the child has died;OR

(a) the child has been seriously harmed AND(b) there is cause for concern as to the way in which the authority, their Board

partners or other relevant persons have worked together to safeguard a child.

MAPPA Reviews

19

MAPPA Serious Case Reviews (MAPPA guidance 2012) are undertaken when both of the following criteria apply:

(a) the MAPPA offender (in any category) was being managed at level 2 or 3 when the offence was committed or at any time in the 28 days before the offence was committed AND

(b) the offence is murder, attempted murder, manslaughter, rape or attempted rape.

Mental Health Homicide Reviews

Mental health homicide reviews are carried out under the Department of Health’s responsibility to commission independent investigations of serious incidents in mental health settings (HSG (94) 27).

The criteria for a mental health review are:

(a) when a homicide has been committed by a person who is, or has been, under the care, that is subject to care programme approach, of a specialist mental health service in the last six months prior to the event

(b) when it is necessary to comply with the State’s obligation under Article 2 of the European Convention on Human Rights whenever the State agent is, or may be, responsible for a death or where a victim sustains life threatening injuries.

The Safeguarding, Quality and Governance team will be responsible for authoring any reports required for statutory reviews, directed by the Head of Safeguarding, Quality and Governance.

Interviewing staff more than once for different processes should be avoided wherever possible. Staff will be offered support and guidance if required to participate in a statutory review and the process will be explained to them fully.

20

APPENDIX A

Immediate actions required after a critical incident

If there is a critical incident while you are at work the following will need to be done:

Make sure the service user or member of staff is safe and call for assistance including emergency services

Discuss and agree with the manager who needs to be notified including family

The member of staff who saw the incident (or who was first on the scene after it happened) must fill in page 1 of the Incident Reporting Form

The line manager must complete the rest of the Incident Reporting form and email it to SSHQRCIN within 48 hours of the incident happening

The line manager must also report the incident (by phone or email) to the next Senior Manager who will escalate as appropriate

If the incident is critical the line manager must also report the incident to the Head of Safeguarding, Quality and Governance

After the manager has reported the incident, witness statements may need to be collected from those people who witnessed the incident

If the manager believes a criminal act may have taken place they will need to inform the police at once. The police will advise the manager of any necessary actions

The manager must ensure the incident form once completed is included in the service user’s notes

If the incident involves a service user placed by a county other than HCC, the home (where applicable) must inform the local area office where the home is located

If the incident involves a service user placed by a county other than HCC, the home (where applicable) must also inform the care manager or social worker in the placing authority of the incident, as soon as possible.

21

Appendix B

CRITICAL INCIDENT REVIEWCIR REVIEW NUMBERINCIDENT DATESERVICE USERS AIS NUMBERREPORT AUTHORSDATE REPORT COMPLETEDVERSION

This review was commissioned by:

Date review commenced:

The Review Team members were:

The Review Team wishes to thanks:

The service user (where applicable) The service user’s family/carer/ staff employed by XXX All of whom assisted in the investigation

TABLE OF CONTENTS

Section Title Page1.0 Executive summary2.02.12.2

IntroductionTerms of ReferenceIssues or concerns raised by the service user and family

3.0 Brief incident overview4.04.14.2

AnalysisExamples of good or excellent practiceAreas where care and support could be developed

5.05.1

Findings of the investigationIdentification of the strengths and weaknesses in current systems

6.0 Learning Recommendations7.07.17.2

Appendices:Appendix 1 –Chronology of key eventsAppendix 2 – Methodology and sources of information used

22

Appendix C

Critical Incident Review Action Plan format

To be completed by the Lead Reviewer and relevant operational manager following the Findings Workshop. The action plan is then added to the CIR to go to the Care Governance Board to be signed off.

No. Key Findings and/or Recommendations

Actions required By Whom Timeframe

Appendix D

Other review options for serious incidents

The Safeguarding, Quality and Governance Team are responsible for the co-ordination of reviews that meet the critical incident criteria, in collaboration with local teams. There are several different types of review that can be undertaken which will be agreed in discussion between the local Service Manager/DSM and the Safeguarding, Quality and Governance Strategic Service Manager, depending on the nature of the incident and the potential for learning.

a) The Records Review Process

A records review is carried out when the service user is known to Adults’ Health & Care and a degree of concern is raised internally or by external partners. Cases that are suited to having a records review are those where:

The circumstances surrounding the incident appear to have been relatively straight forward and

There are some elements of the case that need further clarification which could be gained from a closer examination of the records

OR There is a lack of clarity about the circumstances of the case and a records review

will help to identify what next steps (in terms of reviewing) would be most appropriate.

23

The records review involves looking at the AIS records for the individual involved in the incident. It is a quick fact gathering exercise to inform management decision making and should not be a long, drawn-out process. For this reason, a request for a records review will be undertaken and reported back within five working days of the request being made. Where the concern is more serious the records review will be prioritised and completed well inside this timeframe. The purpose of conducting a records review is to determine if a more in-depth investigation is required and if so, what type of investigation is most appropriate.

A brief records review report will be produced usually in bullet point format which will be emailed to the Strategic Service Manager, Safeguarding, Quality and Governance for review and discussion with senior managers (as necessary) and the Learning and Review Manager. If a further investigation is not required any learning captured at this point will be passed back to the team(s) involved by the Learning and Review Manager. If there is wider learning for the organisation this will be passed to the Learning and Review Manager who will decide the best way to cascade the learning more widely.

b) Single Agency Reflective Workshops

The criteria for a reflective workshop include: Where unexpected death or serious injury has resulted to a service user

(open to and/or commissioned by HCC) and there is concern that the adverse outcome might have been avoided if service delivery had been more effective.

staff have identified a need to reflect on practice to identify learning opportunities.

The decision to undertake a reflective workshop (as opposed to a CIR) will be made by the Safeguarding, Quality and Governance Strategic Service Manager in liaison with the local Service Manager/DSM.

A reflective workshop is a one-off session which allows staff to discuss the case or incident in greater depth with a view to extracting organisational learning. The option of facilitating a reflective workshop can be constructive in cases where a significant concern has arisen that there has been an adverse outcome for a service user which might have been avoidable if services had worked or been provided differently (e.g. placement breakdowns, unplanned emergency admissions to residential care) where:

a number of staff within their team were involved in managing or supporting the case or

where the case has highlighted a pattern of difficulties relating to an area of practice or ways of working which could impact the wider team/ local service over time.

Reflective Workshop ToolkitA toolkit for teams who are going to undertake a reflective workshop has been prepared by the Safeguarding, Quality and Governance Team and is available at CIR Reviewers Handbook v2 . Support in facilitating the workshop is also available from

24

the Learning and Review Manager and the local Safeguarding, Quality and Governance Consultant. In more serious or complex cases the Safeguarding, Quality and Governance Team will lead the workshop.

TimescalesThe Reflective Workshop will be undertaken within six weeks of the agreement between the Strategic Service Manager, Safeguarding, Quality and Governance Team and the operational Service Manager/DSM, that a workshop is needed. This timescale is to allow sufficient time to prepare for the event and organise it to allow as many as possible of the key staff to attend the workshop.

Learning gained from the Reflective Workshop The Safeguarding, Quality and Governance member of staff undertaking the Reflective Workshop will produce a summary of the learning gained and any actions agreed to the Team Manager and staff who attended the workshop. The learning will also be fed back to the Learning and Review Manager to ensure that any wider learning that other teams can benefit from will be cascaded to the relevant teams.

25