SERIOUS/CODE RED INCIDENT REPORTING POLICY and Procedure

Clinical Governance Directorate

CG01 B

Main Author(s): Jane Wiltshire/Heather Kirton

Consultation Route: GM’s, Heads of Nursing, Modern Matrons, Safety, H&R, Facilities, Director of Nursing, Medical Director, Pharmacy, Clinical & Non Clinical Risk Committee

Developed and approved by: Clinical Risk Committee

Approved at Clinical Governance Committee:

Original Date of Issue: June 2001

Date of Review(s): May 2005 May 2007 Summary of Serious/Code Red Incident Reporting Procedure

INCIDENT

1. Address immediate health & safety & medical needs of person/s involved. STEP 1 Reporter 2. Inform Shift or Line Manager (and CSM & Doctor if appropriate) immediately. 3. If a patient is involved, ensure incident recorded in patient health records. 4. Complete AIMS form up to and including box 5. 5. Fax top (blue) AIMS form to either Clinical Risk Department or Health & Safety Department depending on type of incident within 12 hours. 6. Ensure Line Manager (or deputy) receives AIMS form & Managers Report as soon as possible to enable investigation and management of risks.

7. Inform immediately – patient /relatives of facts - General Manager, Clinical Matron, Head of Nursing, Clinical STEP 2 Director, Clinical Risk and/or Health and Safety Services Line Manager 8. Ensure staff involved are supported and statements obtained 9. Implement remedial actions

10. Inform the Director of Nursing/Medical Director immediately/as soon as possible 11. Ensure a preliminary investigation is undertaken & remedial actions implemented STEP 3 General Manager 12. Ensure patient/relatives are informed & kept informed of developments 13. Identify member/s of staff to undertake an in-depth investigation (RCA) 14. Draft a preliminary report for the Chief Executive & Exec Management Team within 24 hours 15. Monitor progress of investigation & ensure report and action plan is completed within 8 weeks of incident 16. Sign off Investigation Report & action plan 17. Ensure implementation of action plan & monitor the effectiveness of actions

18. Inform the Chief Executive & update as appropriate Step 4 19. Ensure all relevant staff within the Trust are informed e.g. Press, Claims Director of Nursing 20. Ensure external organisations are notified as appropriate e.g. SHA /Medical Director 21. Agree a press statement (if appropriate) 22. Decide with the Chief Executive whether to establish the emergency helpline 23. Brief the Trust Board on incident & remedial actions taken 24. Receive the completed Investigation Report and action plan

25 Completed investigation report & action plan approved and signed off by Clinical Risk/Non-Clinical Risk/H&S Committee within 2 months of the incident. Step 5 26. Completed investigation report & action plan endorsed by Clinical Governance Clinical Governance Committee within 3 months of the incident 27. Incident details entered onto database. 28. Themes from investigations provided regularly to Directorates and Specialist SERIOUS/CODE REDCommittees. INCIDENT REPORTING POLICY AND PROCEDURE 29. Review of action plans 6 months after Committee approval to ensure completion CG01 B

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 2 of 21 1. Policy Statement

1.1 It is the policy of North Bristol NHS Trust to ensure

. a prompt investigation is undertaken of all serious/code red incidents and actions implemented to prevent a recurrence. . all patients/families are informed that an incident has taken place & what actions will be implemented to prevent a recurrence.

2. Definition of Serious/Code Red Incidents

2.1 A Serious/Code Red Incident can be defined as

 an adverse event when a patient, member of staff, or members of the public suffers serious harm, or unexpected death (or the risk of death or injury) on Trust premises  where actions of Trust staff are likely to cause significant public concern  any event that might seriously impact on the delivery of service plans and/or may attract media attention and/or result in a settlement following litigation and/or may reflect a serious breach of standards or quality of service  any incident which is graded red using the matrix found in section 6 of the Incident Reporting Policy (page 4).

2.2 All incidents which are graded red on the grading matrix require to be fast tracked. Examples of incidents that would be graded red (but not limited to) are:

 inappropriate surgery performed ( wrong side/wrong patient)  unexpected death  suicide or serious self harm  homicide  bogus staff  serious care management issues e.g. wrong blood type transfused  serious breach of confidentiality  serious medication error  events that affect multiple patients i.e. infected worker, incorrect interpretation of specimens.  significant harm to a child/vulnerable adult reported under child/vulnerable adult protection procedures  maternal deaths  additional interventions as a result of a failure with diagnosis  serious harm resulting in permanent disability

2.3 Examples of non-clinical incidents that would be grade red (but not limited to) are:-

 Serious damage to premises – resulting in patient/staff injury and/or disruption to service  Evacuation of ward/s due to utilities failure e.g. power, medical gases  Malicious activity e.g. tampering with equipment  Security issues – abduction/absconsion  Serious assault on staff/visitor  Incident that results in a fatality or major injury to staff, visitors or contractors  Legal challenges/litigation impending  Dangerous Occurrence as defined in RIDDOR (see Appendix 1 of incident reporting Policy for definitions)

2.4 Additionally, “near miss” incidents that have a likely potential to result in a catastrophic outcome in the event of a recurrence should be reported and investigated as a Code Red, to ensure that risks are minimised proactively. These could be prevented incidents (e.g. wrong patients blood was collected from blood fridge but not administered as it was picked up at the bedside) or no harm incidents ( e.g. patient given medication meant for another patient)

3. Scope of the Policy

3.1 The policy applies to:

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 3 of 21 All staff that have been directly involved in or witnessed a serious/code red incident, discovered that a serious/code red incident had occurred or have been told that a serious/code red incident had occurred

All staff involved with the investigation process after the serious/code red incident occurred

4. An in-depth Investigation

4.1 All serious or catastrophic incidents (code red) require an in-depth investigation using a tool such as Root Cause Analysis (RCA), to be undertaken. An investigation report and action plan will be produced within 2 months of the incident being identified as a code red.

4.2 Managers/clinicians must ensure that an in-depth investigation is undertaken, identifying how the incident occurred so that lessons can be learned and appropriate actions taken to prevent a similar incident happening again. As a result of the investigation it may be appropriate to re-grade the incident.

4.3 Individual staff, in all directorates have received Root Cause Analysis training, however additional support for local Managers/Clinicians conducting a Root Cause Analysis is available from the Clinical Risk Dept. (extension SM 5587)/Health & Safety Services Dept (extension SM 6288).

5. THE PROCEDURE FOR SERIOUS/CODE RED (GRADED) INCIDENTS

5.1 The Serious/Code Red Incident Reporting Procedure is summarised in a flowchart (Page 1)

5.2 If an incident is graded as red (serious or catastrophic) then the following actions will be taken immediately. Due to the serious nature of the incident the senior clinician/manager must notify the Clinical Director/General Manager/Head of Nursing or if out of normal hours the senior clinician/manager and Executive on call.

5.3 The Medical Director or Nursing Director will be notified immediately or if out of hours the next working day. In addition the Medical/Nursing Director will decide whether to notify the Chief Executive. They will also consider whether the relevant external agencies listed in section 10 of Incident Reporting Policy should be notified of the incident.

5.4 The senior clinician/manager or clinical site manager is responsible for:

Office Hours Out of Hours Responsible: the senior clinician/manager Responsible: Clinical Site Manager Informing the patient of the facts (not opinion) of Informing the patient of the facts (not opinion) of the the incident. Patient must be informed before the incident. Patient must be informed before the media. media. Relatives and staff involved should be Relatives and staff involved should be informed as informed as appropriate. (Refer to Being Open appropriate. (Refer to Being Open Policy CG 01 C) Policy CG 01 C) Informing both the Head of Nursing/department, Informing the on-call manager & head of nursing general manager/clinical director immediately immediately Informing the patient’s medical staff immediately Informing the patient’s medical staff immediately or ensuring information is passed on at the end of the shift Informing the Clinical Risk Manager/Health & Ensuring the Clinical Risk Manager/Health & Safety Safety Services and Trust press office immediately Services/Trust press office are notified by leaving a and Claims Department message on ansaphone, and Claims Department Ensuring that staff involved receive support Ensuring that staff involved receive support Ensuring statements are taken from staff who were Ensuring statements are taken from staff who were involved with the incident. These should be legible, involved with the incident. These should be legible, signed, dated and timed (Appendix 3). signed, dated and timed (Appendix 3) Ensure staff have support to write statements eg; staff representatives. Ensuring that any equipment/medication involved Ensuring that any equipment/medication involved in the in the incident is taken out of commission and incident is taken out of commission and securely stored securely stored for later inspection. Unless it is a for later inspection. Unless it is a crime scene, in which crime scene, in which case the area must be case the area must be sealed off and left untouched sealed off and left untouched 5.5 The Clinical Director/General Manager/Head of Nursing are responsible for:

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 4 of 21  Ensuring a preliminary investigation is undertaken within 24 hours in order that a decision regarding the scope of the full investigation can be made

 A judgement regarding what initial action should be taken with staff involved in the incident, should be taken as soon as possible. Objectivity can be maximised by using a structured assessment for example, the NPSA Incident Decision Tree www.npsa.nhs.uk/idt)

 Ensuring that the patient(s)/staff/visitor(s) and /or their relatives have been informed if the individual has been harmed. Refer to Being Open Policy (CG1 C) for further details.

 Collecting all relevant records/documents and reports and if necessary take photocopies of patient health records, as soon as possible. Photocopies made of records should be labelled with the date the copy was made. ITU/Large charts can be copied in Women & Children’s Health Directorate. Contact Sharyn Mckenna (SM 6186) for information.

 Identifying a member/s of staff to undertake an in-depth investigation of the Code Red Incident . Ensuring that they are released of other duties to undertake the investigation and afforded all appropriate assistance. Monitor progress of the investigation, ensuring the investigation is undertaken and report with action plan written within 2 months of the incident.

 Following up any delays and ensuring statements are obtained from staff requested by the investigation lead.

 Ensuring the Investigation Report and action plan go to the appropriate risk committee (Clinical Risk, Non-Clinical Risk, Health and Safety) for review and signing off the action plan which will be presented to the Clinical Governance Committee.

 Drafting a preliminary report for the Chief Executive and Executive Management Team within the first 24 hours

 Ensuring that urgent remedial actions have been take to prevent a reoccurrence of the incident

 Ensuring staff have the opportunity to have a debrief. (See Appendix 4)

 Ensuring, as appropriate, that patients, relatives, staff and the press office are kept informed of developments.

5.6 The Director of Nursing (or Medical Director as appropriate) (or out of hours the Executive on call) are responsible for:

 Informing all other appropriate Executive Directors. Other Clinical Directors/Operations Directors might need to be informed if the incident, or the possibility of reoccurrence, extends to service from other directorates.

 Ensuring that all other departments in the Trust are informed as appropriate of the incident and management of the investigation.

 Legal Advisor who will inform NHSLA,  Press Officer,  Health and Safety Services.  Clinical Risk Management

In addition the following may need to be notified:

 patient’s GP,  Police  Strategic Health Authority. Ensuring the Clinical Risk Manager notifies them electronically according to the SHA policy  Other external agencies which may need to be notified (refer to Incident Reporting Policy section 11)

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 5 of 21  Ensuring the Trust complies with the DOH (2006) Memorandum of Understanding: investigating patient safety incidents involving unexpected death or serious untoward harm, if the incident requires Police or Health Safety Executive involvement.

 Considering how the findings of the investigation and action plan will be communicated to the patient/family

 Ensuring the Chief Executive is informed of the incident and regularly updated.

 Receiving the preliminary report from the responsible Clinical Director/ General Manager

 Agreeing a press statement for the Chief Executive

 Agreeing with the Chief Executive the form of internal/external investigation/enquiry that will be convened

 Agreeing with the Chief Executive if an emergency ‘helpline” is required (See Policy CG01D) to deal with multiple enquiries for a Code Red incident.

 Briefing the Trust Board on the details and remedial actions taken at the first meeting after the incident

 Supporting the investigator by ensuring statements are provided by staff in a timely manner.

5.7 The Head of Clinical Governance is responsible for:

 Liasing as appropriate with the relevant external agencies.  Support the establishment of an emergency ‘hotline’ if required.  Ensuring the Code Red Incident investigation report and action plan are reported to the Clinical Governance Committee  Informing the chairs of the Clinical/Non Clinical Risk Committees that an incident has occurred and an investigation convened.

5.8 The Press Office is responsible for:

 Checking with the ward/department that those directly affected by the event are informed of incident before the media.  Co-ordinating the Trust’s response to the media  Preparing media briefings for patient, relatives, staff and public.  Documenting all information given to the above.  Preparing for VIP visits  Where there has been a considerable amount of media attention inviting a senior media representative to meet with key senior staff some weeks after the incident to review the events and how it will be better managed in the future.

5.9 AFTER THE EVENT

4.9.1 The Clinical Director/General Manager is responsible for;

 Sending a copy of the completed investigation report to Director of Nursing/Medical Director  Implementing recommendations and action plans arising from the investigation of the Code Red incident.  Monitoring the effectiveness of the actions implemented  Ensuring staff receive ongoing support as appropriate. See Guidance Root Cause Analysis Section 7 and Incident Decision Tree (Section 4.5) for further advice and support. Other support measures may include – consultation with the representative, Sick Leave Management, adjustment to duties, improve supervision and additional training.

5.9.2 The Clinical Risk/Non-Clinical Risk/Health and Safety Committee is responsible for:

 Reviewing the investigation report and signing off action plan  Presenting a summary of the Incident investigation and action plan to the Clinical Governance Committee.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 6 of 21  Monitoring progress of action plan implementation at 6 months or sooner if appropriate  Reporting to Clinical Governance Committee on completion of tasks identified in the action plan of the Investigation Report and alerting the Committee to any concerns about non-completion.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 7 of 21 Root Cause Analysis Investigation Pack

A guide for Managers leading or undertaking the RCA into a Code Red Incident

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 8 of 21 Guidance for Staff Undertaking a Root Cause Analysis (RCA) Investigation for a Serious/Code Red Incidents

1. Introduction

1.1 The purpose of this guidance is to provide a framework for staff to work to when they are required to undertake a RCA for a serious/code red incident.

2. Definition of a RCA

A root cause analysis is:

a structured investigation that aims to identify the true cause(s) of a problem and the actions necessary to eliminate it. (Anderson and Fagerhaug 2000)

3. Starting the Investigation

3.1 Which incidents will be investigated in-depth?

3.1.1 The senior clinician/manager as soon as they are notified will initially decide whether the incident warrants an in-depth investigation. This may be triggered by a high score when graded or there may be other circumstances related to the incident. An AIMS form will be completed and processed as required in the Incident Reporting Policy.

3.2 Who should investigate?

3.2.1 The Clinical Director and/or General Manager for the Directorate where the incident had occurred will:

 Identify member/s of staff to undertake the RCA. One member of staff should co- ordinate the RCA & one should have relevant expertise in the area of the incident.  Agree terms of reference for RCA scope.  Provide secretarial support  Decide whether to send any member of staff off duty if events have been sufficiently traumatic or whether the seriousness of the event warrants staff to be off whilst disciplinary action is considered. Refer to section 2 (NPSA Incident Decision Tree) of the policy for occasions where this may need to be considered. In those incidences seek advice from HR Advisors prior to proceeding. Photocopies should be labelled with the date the copies were made.

3.2.2 The Investigator/s will:

 Ensure all patient and other relevant records are collected and photocopied as soon as possible.  Review the case records of the patient to gain useful background information on the patient and have an overall view of events and any contributory factors, which may have affected the events.  Produce a list of key staff involved in the incident and request statements from them.  Decide whom ( if appropriate) to interview and in what order they should be seen.  Decide whether expert advice/comment should be sought from Trust staff not involved in the incident. This may be in the form of a report or interview, or during the consultation stages of the report’s development.  Visit the site where incident occurred, if relevant

3.3 Obtaining statements from staff

3.3.1 The Investigator/s via the staff’s line manager will request a statement of events from staff involved in the incident. Refer to Appendix 2 for further details. In the event that the staff’s line manager is involved in the incident then their line manager will be responsible for requesting the statements

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 9 of 21 3.3.2 The statement should be:

 Accurate, fact not opinion  Concise  Avoid hearsay  Relevant  Legible  Signed and dated only after the author is satisfied with all aspects and it is a true recollection of events

3.3.3 Statements should be written as soon as possible to maximise accuracy of witness’s recollections and to aid the investigation process. However their level of distress will be taken into account.

3.3.4 The statement must not be discussed with anyone involved in the incident and provided before other events occur e.g. debriefings, preparations for coroners court, on order to prevent influence over statements subsequently produced.

3.3.5 Staff may wish to seek support from their Line Manager, Clinical Supervisor or Professional Body. This should not delay the investigation process, however in the event of a foreseeable delay information should be provided verbally to the investigator

3.3.6 Further guidance on statement taking can be obtained from a number of Trust staff e.g. Trust’s Solicitor, Deputy Director of Nursing, Local Security Management Specialist, Clinical Risk Department

3.4 Staff preparation

3.4.1 Any investigation is likely to be stressful for staff involved and therefore preparation of staff is crucial in reducing stress.

3.4.2 It should be made clear to staff that the investigation is to help find out what occurred and learn lessons from the incident - it is not a disciplinary process. It is important not to apportion blame in investigating incidents so staff feel able to be as open & honest as possible.

3.4.3 An interview schedule should be agreed with sufficient warning for staff to arrange cover and gather their thoughts in advance.

3.4.4 A letter should be sent to all staff who will be interviewed, it should include:

 A brief explanation of the purpose of the investigation  What will be covered during the interview  Who will be conducting the interview  How long the interview will last  Information on bringing a colleague/friend/staff representation if they wish  Terms of reference for investigation attached (to include the purpose is to gather facts not opinions and a statement of the events)  Who they can contact for support  Whether the interview will be audio taped and why

4. The Investigation

4.1 Undertaking the Interview

4.1.1 The interview should be undertaken in private, undisturbed and away from the immediate place of work.

4.1.2 If possible it should be conducted by a pair of investigators, one should lead and one should record responses.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 10 of 21 4.1.3 The purpose of interview should be explained at the beginning.

4.1.4 If the interview is going to be taped, the purpose of taping and what will be done with the tapes after the investigation has been completed, should be explained.

4.1.5 The investigator/s should be supportive and understanding and not make adverse comments or judgements

4.1.6 If the staff member wishes someone else to be present for support this should be permitted.

4.1.7 During the interview the following factors will need to be explored:

 Establishing the chronology of events  Identifying what aspects of care deviated beyond safe limits of practice e.g. failure to monitor/act, wrong treatment given, not seeking help when necessary.  Identifying any contributory factors  Identifying areas of good practice

4.1.8 At the end of each interview the investigator/s will

 Invite the interviewee to make any other comments or ask any other questions  Explain what will happen next in the investigation.

5. Preparation of Report

5.1 The investigator/s should analyse the incident, by mapping the event and asking the following questions:

 What happened?  How did it happen?  Why did it happen?  Who was involved?  What factors contributed to it happening?  What can we learn from this and what changes should we make to prevent a re-occurrence?

5.2 There are a number of tools and methods available to help organise all the information. See section 7.4 for contact details. Mapping the information clarifies what is known and what gaps there are.

5.3 All person identifiable details must be anonymised in the report e.g patient X, Staff Nurse 1. The use of initials is not advised, as they may still enable identification of individuals.

5.4 The report should contain the following sections:

. Summary ( including immediate action taken) . Background . Methodology . Findings (List problems identified) . Root Causes Identified . Contributory Factors . Conclusions . Action plan and time-scales allocated to a nominated person. . Author of report & date . Appendices - timeline (details of events in chronological order)

5.5 The draft timeline should be circulated in confidence to relevant staff for them to check accuracy. Amendments must be made prior to the final report being published. Password protection is required for electronic circulation of these reports.

5.6 The report and action plan must be completed within one month of the incident.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 11 of 21 5.7 The report will be sent to the Clinical Director/Head of Nursing/General Manager for actioning and to Clinical Risk Management and Health & Safety Services for escalation through the Trust Committee Structure.

6. Post Investigation

6.1 A copy of the report and action plan will be sent to the relevant risk committee by the author, i.e. Clinical Risk, Non-Clinical Risk or Health and Safety. The Director of Nursing/Medical Director and Claims Department will also be sent a copy of the report. The Committee will review and sign off the action plan.

6.2 The relevant committee will monitor progress against the agreed actions and report to the Clinical Governance Committee on completion of all actions

7. Support for Staff

7.1 Any investigation can be stressful for staff therefore following the investigation all staff involved should be offered the opportunity to partake in a de-brief. (See appendix 1)

7.2 Staff who have access to clinical supervision will have the opportunity to discuss the issues with their supervisor.

7.3 Staff who do not have access to clinical supervision may require an alternative method to discuss the issues raised in the incident and subsequent investigation.

7.4 Giving information to staff about positive actions being taken helps to reinforce the value of the reporting and investigation procedure, whilst simultaneously reducing fears of personal blame.

7.5 Long term support may be required for staff still traumatised, Occupational Health /HR should be contacted for advice.

8. Support for Staff if case is referred on to the Coroner or Litigation

8.1 In the event the case is referred on to the Coroner or the Trust is informed of a potential claim, the Claims & Litigation Department will be responsible for:

 Informing all staff who may be required to make a statement or be called as a witness. This may in some circumstance be via the Clinical Director, General Manager, Head of Nursing or Directorate Risk Lead

 Informing staff of progress of case

 Preparing staff with the Trust’s Solicitors for appearing in Court

 Supporting staff if required by accompanying staff in court.

8.2 The line manager of staff involved in the above cases may seek further support or advise staff to seek support from:

 The Directorate’s Human Resources Advisor  Staff Counsellor

9. Further Help/Advice

9.1 Support for local managers/clinicians conducting a root cause analysis is available from

 Directorate – each directorate has a number of key staff who have been trained to use root cause analysis methodology

 Clinical Risk Dept. (Extension SM 5587)

 Health & Safety Services (extension SM 6288)

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 12 of 21 Appendix 1

Clinical Governance Directorate

Critical Incident Debriefing Guidance

1. Introduction

1.1 The purpose of this guidance is to provide a framework for staff who are required to undertake a debriefing session following a serious critical incident.

1.2 Debriefing staff who have been involved in a serious critical incident should be an integral part of any follow up action/s.

1.3 As in line with the Trust’s Risk Management Strategy, this protocol should follow the principle of ‘open and learning ‘ when staff are being debriefed.

2. What is a debrief?

2.1 It has been described as ‘a group meeting to review the impressions and reactions of survivors, bereaved or helpers experienced during or following critical incidents, accidents or disasters.’ However it should be noted that individuals can also be successfully debriefed using the same principles.

2.2 Debriefing also allows the Trust to evaluate its response and identify lessons to be learnt at operational, tactical, and strategic level.

3. Why should we debrief?

3.1 Debriefing can help people cope with and recover from the incident after effects. It helps participants understand that they are not alone in their reactions to distressing events and provides them with an opportunity to discuss thoughts and feelings in a controlled, safe environment.

4. What incidents will require a debrief?

4.1 This guidance was originally developed for the benefit of emergency services and military personnel. However, the principles can be transferred to a healthcare setting and therefore incidents which would require debriefing would include, though not limited to, the following:

 Instigation of the Major Incident Plan  Instigation of the Service Continuity Plan e.g. power failure, fire  Incidents requiring instigation of “Help Line”  Baby/Child Abduction  Death/serious injury to patient/s following a serious healthcare service failure/near miss.  Violence toward staff, including hostage situations  Sudden unexpected death patient/colleague/visitor

In addition a debrief should be considered when staff were clearly distressed by a serious/unexpected event/s and/or where lessons could be learnt trustwide

5. When should the debrief be undertaken?

5.1 As soon after the incident as possible, ideally within 24 to 72 hours post incident.

5.2 The holding of the debrief should not delay the commencement of the investigation process

5.3 Staff must be asked to provide a statement to the investigator prior to attending any debrief.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 13 of 21 6. Who should determine whether debriefing is required?

6.1 The on-call General Manager will have the responsibility for determining the extent and the detail of the initial debriefing and reporting back post debriefing to the appropriate Executive Director/s who will determine whether a general debrief should be undertaken.

6.2 In the event of a maternal death or baby abduction, the Supervisor of Midwives will determine the extent and detail of the initial debriefing.

7. Who should undertake the debrief?

7.1 The debriefing session should be undertaken by staff who have the required skills to undertake the process e.g. group dynamics, counselling. Refer to the Trust’s Major Incident Plan where key Trust staff have been identified.

8. There should be two types of debriefing 8 8.1 Initial Debrief

This is where:

 The end of the incident is formally acknowledged.

 Staff are provided with information to complete the picture of the incident and its response.

 Staff are allowed to share their experiences.

 All staff involved are registered so that any follow up arrangements can be comprehensive.

 A ‘signposting’ service is provided with regard to any planned arrangements and lessons learnt.

 Staff are advised that arrangements are being made to hold a series of meetings to disseminate the general information to as many staff as possible. If possible date, time and venue is given.

8.2 General Debrief

 As many staff involved in the incident as possible to attend.

 Dates, times and venues to be disseminated to all concerned.

 To take place within 48 hours.

 Contact numbers of support services to be provided (internal & external), eg: Managing traumatic events for you and your team leaflets – available from Occupational Health Services.

 Make notes of concerns/issues raised at meeting, ensure that they are followed up.

 Staff who are unable to attend should be sent a copy of the notes made from the meeting

9. Where should it be done?

9.1 In a room large enough to hold the expected amount of staff, away from interruptions or distractions. Flip charts, pens, beverages, tissues to be available, with contact numbers for staff support services.

10. What support should be provided for staff after the incident?

 A letter of acknowledgement should be sent to all members of staff who were involved in any way with the incident. It should be drafted and signed by the Chief Executive within 72 hours of the end of the incident being declared. However, in some instances, it may be more appropriate for the letter to be signed by the Clinical Director or Head of Nursing. This very much depends upon the nature of the incident.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 14 of 21  Staff should be granted leave of absence, if necessary, at the discretion of their line managers.

 Consider a return to work interview with the affected staff

 If possible, and if necessary, re-assign staff to new duties/areas eg; if staff workplace is temporarily out of action.

 Provide staff with support services and time off to attend appointments etc.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 15 of 21 11. How should actions be followed up?

 A senior member of trust staff will be nominated by the Executive Management team and will be responsible for following up actions post incident

 Follow up will depend on circumstances but might include revision of plans and procedures, strengthening liason with other agencies, devising small exercises to test alternative approaches.

 Where there has been a considerable amount of media attention a senior media representative will be invited to meet with key senior staff some weeks after the incident to review the events and how it could be better managed in the future.

 Lessons learnt and actions implemented to prevent a similar occurrence will be reported back to staff within 2 months via special meetings, trust intranet & Insite magazine as appropriate.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 16 of 21 Debriefing Checklist

(For Managers required to initiate a debrief following a serious incident)

1. Time – should normally be within 24hrs of incident

2. Room – large enough to hold expected staff

3. Staff facilitating session – staff member with necessary skills

4. Notify all staff involved:

– contact individuals – notices in communal facilities eg; staff rooms/toilets

5. Equipment :

– flip charts - pens

- tissues

6. Beverages – order tea/coffee/water to be available.

7. Attendance Sheet:

- staff to sign in  - ensure staff contact numbers are included

8. Note taking – organise someone not involved in the events to take notes of debrief.

9. Contact numbers – of counselling/support services to be available

10. Follow up - advise staff what will happen next eg: required to make formal statements, type of inquiry – informal, police, HSE, Fire (Give out guidelines for writing a statement)

11. Feedback – report back to on-call Director

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 17 of 21 APPENDIX 2 PREPARING A STATEMENT OF FACTS

This guidance is intended to assist staff when requested in preparing a statement related to an incident they were involved in or they witnessed. Additional statements may be taken by enforcing authorities such as the Police and the HSE.

The information contained within the statement enables the investigator to build up a picture of what happened and help them to understand how the incident occurred.

Any information given will be treated as confidential and will be stored in a secure place.

Any statement, other than those written for the Claims Department in contemplation of a claim against the Trust, may be disclosed to the patient, and if a minor or deceased, to their family, the Coroner, Claimant's Solicitor, the police, judges in the criminal and civil courts and the local authority. This applies regardless of the form of the statement eg it can be in writing as a formal statement or as a letter.

Where possible, the author of the statement would be informed of the request for disclosure prior to disclosure.

The statement must be an accurate and factual account of the individual’s involvement in the incident. It should focus on:  what they said  what they did  what they saw  what they didn’t do  and why

It should be made clear in the statement whether the information is obtained from the patient’s records or other documentary evidence rather than from memory.

The statement should be a full and complete account of involvement in the events leading up to and during the incident.

The Statement should:

 Start with full name, designation and department

 Include NMC, GMC or equivalent registration number if applicable

 State how long they have worked in particular department/service

 Provide a detailed chronological narrative of their involvement. Set out in paragraphs.

 Detail each visit to the patient, examinations and treatment performed stating date and time at which the contacts occurred.

 State precisely what care they gave to the patient including any observations carried out and whether or not these were within normal limits

 If they liased with other members of staff for advice, or to discuss care, state who the persons were and their designation e.g. Dr John Smith (duty SHO)

 Clearly print their name and sign and date the statement at the end of each page

The above bullet points may require to be amended for non-clinical incidents.

Staff who require assistance to write their statement should contact their line manager/staff representative in the first instance.

Staff should take a copy of their statement and store in a safe place for future reference Adapted from the NPSA RCA Tool Kit – Guidance on Witness Statements

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 18 of 21 STATEMENT OF FACTS – SHEET 1

Statement of (please print full name)

Job title of Staff Witness

Professional Registration Number e.g. NMC, GMC

Work address of Witness

Business telephone number

Non Staff Witness (e.g. patient/relatives/other)

Contact number of non-staff witness

Non Staff - Describe reason for being present to witness events

Statement taken by (full name & job title)

This statement (consisting of pages each signed by me) is true to the best of my knowledge and belief.

Signature Date

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 19 of 21 STATEMENT OF FACTS – SHEET 2

Date & time of incident

Location of incident

Names & titles of other witnesses

Please now describe what happened, including what factors contributed to this occurring, and what actions were taken.

Name (in capitals) and signature

Page no.

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 20 of 21 WITNESS STATEMENT - CONTINUATION SHEET

Name (in capitals) and signature

Final version – June 07 Serious/Code red Incident Reporting Policy CG01 b Page 21 of 21