Management of Public Health Incidents: Guidance on the Roles and Responsibilities of NHS led Incident Management Teams - October 2011 (Updated July 2013)

KEY FUNCTIONS OF INCIDENT MANAGEMENT

Introduction

79. Local incident management plans should describe how the key functions in managing incidents will be implemented in each NHS Board area. These include the following and are described in more detail below:

• Surveillance, notification and reporting
• Identification and initial response
• Investigation
• Risk assessment
• Risk Management
• Risk Communication
• Audit, evaluation and documentation

Surveillance, notification and reporting

80. An essential part of incident management is the recognition of a change in the distribution of illness or the occurrence of an illness of major public health significance. To this end surveillance, i.e. the timely collection and collation, analysis and dissemination of information for action, is a vital tool. Following the implementation of the Public Health (Scotland) Act 2008, all registered medical practitioners have a statutory responsibility to notify NHS Board Health Protection Teams of any of the specified diseases or health risk states where there may be a significant risk to public health. These should be reported by telephone on the basis of reasonable clinical suspicion rather than awaiting laboratory confirmation. The telephone call should be followed up by written notification using the electronic system, Scottish Care Information (SCI) Gateway, within three working days or by written notification. (Schedule 1 of Public Health (Scotland) Act 2008 http://www.legislation.gov.uk/asp/2008/5/schedule/1)

81. Local diagnostic laboratories are also required under the Act to notify specified organisms within the same working day, followed by written/electronic notification within ten days. (Schedule 1 of Public Health (Scotland) Act 2008

http://www.legislation.gov.uk/asp/2008/5/schedule/1)

82. NHS Boards should have in place systems, which enable them to analyse and interpret information collected through surveillance and identify:

• an increase in the incidence of a communicable disease, or of an illness which may be due to an environmental hazard, over that expected for a specific person, place or time;
• the clustering of cases, in person, place or time, of communicable disease or illnesses which may in due to an environmental hazards;
• the occurrence of a single case of a serious infection with significant public health implications;
• the occurrence of a novel pathogen
• a clustering of cases of severe illness which have an unusual clinical presentation;
• a clustering of unexplained illnesses; and
• the occurrence of an event which has led or has the potential to lead to a community or significant proportion of the population, being exposed to a hazardous agent.

83. NHS Boards should agree with their partners reporting mechanisms which include criteria ('triggers') for notification of certain types of potential incidents (such as water failures) requiring further investigation and risk assessment. The Public Health Act has established a framework and timeframes for registered medical practitioners and diagnostic laboratories to notify the Health Protection Team (HPT) of diseases, organisms or health risk states. However, NHS Boards should also have plans in place requiring that partner agencies report incidents when:

• Statutory agencies responsible for monitoring air, food and water quality, have information that indicates there may be a risk to public health; and
• Emergency services reporting incidents in which the public may be/have been exposed to harmful agents such as chemical spills.

84. In addition to the formal notifications systems described above early identification of a threat to the public health may be identified through informal epidemiological intelligence based on excellent working relationships with local partners e.g. EHOs, GPs, clinicians but also with care homes, schools etc. This facilitates the possibility of early intervention and prevention of illness.

Identification and initial response

85. The occurrence of one or more of the events indicated above should alert the NHS Board and in particular the CPHM to the possibility of an incident. Incidents, particularly those involving more than one NHS Board area, may be recognised through the national surveillance system operated by HPS. In certain circumstances e.g. an immediate response to a chemical incident, one or more agencies may have to take urgent action to protect the public before notifying the NHS Board. However, the NHS Board must be notified as soon as the initial control steps have been taken. This will allow the NHS Board to activate a multi-agency response to implement further measures to protect the public.

86. On recognition of one or more of these events, the NHS Board should ensure that:

• all relevant agencies with a responsibility for the investigation and management of the incident are informed;
• steps are taken to gather further information about the cases and how they may have been exposed to the hazardous agent;
• an initial risk assessment is undertaken;
• if possible, a working hypothesis as to the cause of the incident is formulated;
• urgent control measures are put in place to protect public health (if necessary).

87. If the initial risk assessment indicates that there are cases of an illness which have significant public health implications and/or there is a probability of the public continuing to be exposed to an infective or other hazardous agent, steps should be taken to convene an IMT. Based on an initial risk assessment, the NHS Board should reach a view in conjunction with the partners about the need for specific control measures. These should be instituted as soon as possible and should not necessarily await the convening of an IMT if there is an urgent need to protect public health.

88. Some incidents may be over by the time they are reported or discovered. In this case the focus of the investigation will be on identifying the cause and on the prevention of a future episode. An incident may be limited in terms of size and clinical significance, e.g. an outbreak of norovirus in a care home. In such instances it may not be necessary to convene an IMT. However, should the outbreak escalate or be a cause for concern, an IMT may be required.

89. Once the CPHM has carried out the initial risk assessment, a decision should be made on how the risk is likely to be perceived by the public; how and when it should be communicated and the best medium for doing so. If there is a need for urgent preliminary communication, this should not await for the IMT to meet. There may also be a need to involve the Scottish Government communications team depending on the nature and scale of the incident.

90. NHS Boards, once they have assessed that an incident is or may be occurring, should contact both HPS and the appropriate member of the CMO's team within the Scottish Government. This contact should be made by telephone during office hours on 0131 244 2804 and for out of hours and as the situation requires, contact should be made with the on-call team member of the CMO and Public Health Directorate. This contact should be made via the on oncall mobile number 07824 087787. The CMO and Public Health Directorate team will follow the 'Protocol for informing Ministers about significant public health incidents and outbreaks' (Annex I).

91. On receipt of an alert, HPS should agree with the notifying NHS Board whether agencies other than those immediately engaged in the management of the incident, should receive an appropriate alert. This assessment should be based on the likelihood of the incident spreading to other NHS Boards, of it receiving extensive media coverage likely to cause public concern or of it being of such a scale that mutual aid may be requested. HPS should indicate in the alert the level of response required by the receiving agencies:

• for noting - no action required;
• for action - monitoring only;
• for action - monitoring and wider dissemination to NHS; or
• for action - monitoring, wider dissemination and specific measures to be taken by recipient.

92. When appropriate, HPS will also decide, in conjunction with SGHD and HPA, if an Early Warning Response System (EWRS) or International Health Regulations (IHR) notification may be required. HPS should also record details of the incident received from the notifying NHS Board in an Incident Surveillance System developed to monitor the overall number of these types of events occurring in the country, to facilitate assessing their overall impact and the best means of managing them.

Investigation

93. From the information gathered from the initial investigation, it may be possible to form a working hypothesis about the type of exposure to the infective agent or the environmental hazard involved, the source and level of that exposure, the nature and size of the population exposed or likely to be exposed, and the degree of risk to the public health. The IMT will then decide how to progress a fuller investigation to test the hypothesis.

94. The investigation should usually consist of three elements:

• an epidemiological investigation;
• an investigation into the nature and characteristics of the implicated hazard (in communicable disease incidents, this would be a microbiological investigation); and
• a specific investigation into how cases were exposed to the infective agent or other hazard (e.g. food supply and hygiene, hygiene in healthcare settings) to inform control measures.

95. Most incidents merit detailed description, and a descriptive epidemiological study of cases should be carried out. The IMT should agree a case definition for the purpose of the incident and regularly review and revise this definition, as appropriate, throughout the incident investigation. Data collection forms should be available prior to the incident under investigation, and should be modified for the purposes of the incident. Information from individual cases should be collated preferably using an appropriate computer software package. Standard epidemiological output, e.g. epidemic curve, incidence rates and exposed populations, line listing, time line etc should be presented to the IMT. The working hypothesis may then need to be reviewed. Based on the outcome of the descriptive epidemiological investigation, the IMT may decide to carry out an analytical epidemiological study. A decision to carry this out should be made in liaison with HPS and NHS Boards should normally expect support from HPS in carrying out these studies.

96. It is essential to involve scientific, especially diagnostic laboratories, as early as possible in the investigation of an incident. The microbiologist on the IMT should advise on the taking of appropriate specimens and arrange for relevant investigations. This should include liaison with the relevant reference laboratory in Scotland, or other specialist laboratories in the UK. The public analyst should arrange for appropriate investigation of non human sample e.g. food samples. It is essential that accurate consistent results of tests are available as rapidly as possible to the IMT. The IMT should therefore consider carefully the best use of laboratory resources available, taking into consideration turn-around times for testing and reporting. The laboratory may need to prepare for a substantial increase in samples and plan for surge capacity. Guidance on the submission of clinical samples should be a high priority and should be communicated to all relevant clinicians. As part of the incident investigation the Consultant Microbiologist should advise on the information required by the laboratory to ensure prompt identification of such samples and to distinguish them from other samples.

97. Specific investigations should be undertaken into the reasons for and circumstances in which cases were exposed to the hazardous agent implicated in the incident. This will often involve the taking of appropriate samples for microbiological or other laboratory testing. It also may involve tracing the likely passage of the agent causing illness from the most probable source of contamination or infection to the specific circumstances in which the case was exposed to it. NHS Boards should liaise with Local Authorities and other agencies in ensuring that relevant protocols for this type of investigation are in place.

98. In the early stages of an investigation, the IMT should consider whether a criminal investigation is likely to ensue. If so, evidential procedures should be followed as far as possible but without jeopardising the investigation or control measures.

99. The IMT Chair and others within the IMT who have powers to conduct investigations with a view to potential future criminal proceedings, should individually and collectively consider the implications of any potential criminal investigation at the outset. It is therefore essential that all IMT members and their respective organisations record and keep detailed and accurate records from the outset of any investigation. Instigating critical control measures should initially be the objective of the IMT collectively. However, insofar as any future criminal proceedings are concerned, the IMT should be aware of the potential impact of the Supreme Court decision in Cadder v HMA [2010] UKSC 43 on their evidence gathering procedures. This should be considered by the IMT at the outset, with advice as necessary being taken by legal advisers and Crown Office policy contacts.

100. The results of the epidemiological, microbiological and environmental investigation must be considered together before reaching a conclusion as to their significance to the control of the incident. This should be linked to previous knowledge of the illness involved and local circumstances. Considering the findings from each investigation singly may be misleading. IMTs should take care to assess where the findings may be coincidental. In particular the IMT should review associations which may be considered causal and assess whether there is evidence of bias in the investigation and/or the strength of a specific association.

Risk Assessment

101. Based on the findings from the investigation and an assessment of the effectiveness of control measures taken, the IMT should assess the ongoing risk to the public from exposure to the hazardous agent involved in the incident. The purpose of this assessment is two-fold:

• to estimate the probability of the public continuing to be exposed to the hazard, and
• to estimate the level of illness likely to arise in the population exposed.

102. Risk assessment essentially entails appraising the balance of evidence collected in the incident investigation and reaching a view as to whether it indicates that there is a significant threat to public health. The risk assessment should be dynamic and regularly reviewed e.g. at each IMT. It should involve:

• defining the impact on health associated with the agent identified as being the hazard to health;
• defining the probable or possible vehicle for the exposure of the agent and its distribution in the community exposed;
• identifying the population exposed or likely to be exposed and their susceptibility to the hazardous agent; and
• estimating the overall probability of there continuing to be an ongoing exposure and the likely scale of ill health resulting from this exposure.

103. Conclusions derived from this process are principally a matter of professional judgement. However, for reasons of public accountability and understanding, it is essential that this process is as transparent as possible. The IMT should discuss and record the outcome of the risk assessments. Once the risk has been assessed a decision should be made on how the risk is likely to be perceived by the public. This should inform the development of specific communications to the public about the risk and how it is being reduced.

Risk Management

Control measures to prevent further exposure

104. The principal objective of control measures is to reduce the risk to public health. Control measures may be directed at the source of the exposure and/or at affected persons to prevent secondary exposure to the agent.

105. Specific control measures will vary according to the type of incident. In summary they may include the following:

• advising specific groups or the general public on how to avoid and minimise risks e.g. avoid contaminated sites, condom use, preventing needle sharing, safe food handling, limit exposure;
• delivering healthcare interventions to prevent the transmission or development of illnesses or their complications e.g. antibiotics, chemical antidotes, immunisation;
• implementing hygiene measures which reduce or eliminate contamination with hazards e.g. respiratory and hand hygiene, environmental decontamination, dust control measures;
• review the current standards of practice to identify areas for immediate improvement;
• curtailing normal daily activities or services e.g. excluding from school or nursery, closure of food preparation or retail premises, either through voluntary agreement or enacting regulatory powers, closing wards/care homes to admissions, limiting public access, identifying circumstances in which usual practices (agricultural, industrial, commercial) should be modified;
• food withdrawals or food warnings; and
• providing alternative arrangements for normal services e.g. drinking water supplies.

106. A range of agencies may be involved in controlling an incident. Many of the measures taken have to be carried out within a legal or statutory framework. At times voluntary agreements will be sought with a range of parties implicated in the incident e.g. food retailers. Wherever possible these voluntary agreements should be recorded and if possible signed by both parties. It is important that professionals and the general public are provided with relevant information on the control measures being taken so that they can understand their relevance to their own safety/practice.

107. Control measures taken by one agency will have implications for those taken in another therefore it is essential that the IMT maintains an overview and co-ordinates such measures. When controls involve or have the potential to involve legal proceedings, it is important that the local Procurator Fiscal's department is kept fully informed. The agency responsible for a specific control measure should check that the measure is being put in place in the time required and is having the desired impact as defined by the IMT and report on this to the IMT.

Patient Assessment and Care Measures

108. A major public health incident can lead to significant pressure being placed on primary care and hospital services. It is important that in such instances the IMT establishes effective liaison with senior managers of the NHS Board, hospitals, pharmacists, GPs, Primary Care and Community Health services.

109. The IMT should request advice from clinical colleagues on the appropriate management of patients directly involved in the incident. Guidance on the clinical management of patients should be provided to Primary Care, Out of Hours Services, NHS 24 and hospital doctors.

110. The IMT may also need to consider the need to develop plans for the enhancement of specialist hospital based services; support arrangements for GPs and other primary care services; mechanisms to coordinate services between primary care and between and among different hospitals (if more than one is involved). The plan should also indicate arrangements for the admission of patients; the content of communications to professionals, patients and relatives; contact points for enquiries and infection control measures to prevent transmission in healthcare settings.

Risk Communication

111. NHS Boards should use the Health Protection Network guidance 'Communicating with the Public about Health Risks' (2008) to inform their risk communication strategy. http://www.documents.hps.scot.nhs.uk/about-hps/hpn/risk-communication.pdf

112. Risk communication is an essential part of the process of managing public health incidents. As the main issues to be covered in these communications generally concern hazards to the public health, NHS Boards should take the lead in decision making on risk communication.

• From evidence in the scientific literature effective communication demands a presumption in favour of transparency and openness. Not being open puts at stake the perceived trustworthiness of the agencies involved in managing risks.
• When communicating about risks, health agencies should be clear about the objectives they are pursuing, and identify any key issues which will influence the impact on the public from the communication. For the general public to be engaged, communicators must be perceived to be trustworthy and believable.
• Plans for public health incidents should contain clear procedures for risk communication e.g. special helplines, leaflet distribution, use of the internet, public meetings, briefings for professionals and the SG, special arrangements for businesses and institutions (e.g. hospitals), media handling.
• Communications should contain messages that are clear, relevant and timely, acknowledging uncertainties and should explain as far as possible the risk to the public in terms of probabilities and by comparing the current risk to others.
• Mechanisms should be in place to monitor the impact of communication on public perception of risk and how this is reported e.g. monitoring the number and nature of calls to a helpline and the extent, content and tone of media coverage.

113. Decision-making about communication of public health risks should be based on a presumption of openness. As far as possible communications should be founded on factual and meaningful evidence but if there is doubt as to the reliability of this, the public should be informed of this and uncertainties acknowledged. The IMT should keep in mind the particular need for specific communications aimed at defined risk groups (e.g. immuno-compromised, pregnant women), those with literary difficulties or sensory deficits (hearing or vision), or for ethnic groups. In addition, the IMT should consider the need for advice to be available in different languages. Decisions on risk communication should be recorded. Decisions not to communicate about actual or potential risks to the public health even when these are uncertain should be justified and recorded.

114. If an incident escalates significantly and there is a national response or SG emergency procedures are invoked it is likely that communication and handling will be discussed and agreed with SG.

Communications Plans

115. NHS Boards should have a communications plan which indicates how they will provide information about the incident and its control to the following key groups:

• the key agencies involved in managing the incident;
• professionals involved in diagnosing, treating, or advising patients who are, or could be cases of infection or toxic exposure;
• the general public and in particular the community directly affected by the incident;
• HPS and SGHD; and
• Contribute to multi-agency response via SCG structures, if appropriate

Intra and inter agency communications

116. If time allows the CPHM should brief the other agencies likely to be involved in responding to the incident prior to the first IMT meeting. Information should be regularly updated as appropriate. As part of their emergency plans, NHS Boards should maintain a contact list (including out of hours arrangements) for representatives for all key agencies. NHS Boards should ensure that there are procedures to ensure that on notification, information is passed to Director of Public Health, senior management and the communication team. The relevant local authority and HPS should be informed about suspected incidents. CPHMs should be informed of all hospital infection incidents (and thence will report to DPH), regardless of whether chaired by ICD or CPHM. The hospital infection incident assessment tool (HIIAT) states that in hospital infection incidents assessed as HIIAT green the CPHM should be informed; if assessed as amber or red, there should be engagement with CPHM (see Annex D)

117. NHS Boards must notify suspected public health incidents to the SGHD, if possible prior to the first meeting of the IMT. Notifications should be made to a Senior Medical Officer (SMO) in line with the protocol agreed with Scottish Government Ministers in 2007 (excluding HAI incidents in hospitals for which separate arrangements apply - see Annex D). The IMT should agree clear channels of communication and reporting lines at the first meeting. This should include a single channel of reporting in to Scottish Government. For HAI incidents, the IMT chair should take cognisance of the guidance in Annex D. If the incident is thought to be the result of foodborne exposure, the Food Standards Agency (FSA) should be notified. SGHD should receive regular updates on the progress of the incident, via the SMOs, during working hours on 0131 244 2804 and out of hours, updates should be made via the CMO and Public Health Directorate on call mobile on 07824 087787. If the incident is related to a public drinking water supply, Scottish Water should notify the Drinking Water Quality Regulator (DWQR). SGHD and the DWQR should liaise to ensure a consistent message from the SG.

118. During an incident, a range of professionals working in diagnostic laboratories or clinical services will require information about the nature of the infection, care arrangements, diagnostic testing, advice to the public and the scale of the outbreak and steps taken to control it.

119. NHS Boards should have in place mechanisms for the effective transmission of information within as short a time-scale as possible. This should involve the use of e-mails, ensuring that secure e-mail addresses are used for sensitive or patient identifiable data and alternative routes of communication are used for those e-mails which do not fulfil these criteria. Communications should be recorded. However, it is important to appreciate that when investigating and managing an incident, colleagues may not be at their base so any urgent communication should still be by telephone.

120. Where deaths have or may have arisen as part of an incident, the IMT Chair should inform the Procurator Fiscal.

Communications with the public

121. To help allay any unnecessary public anxiety, communications should be made as early as possible in the management of the incident. This requires tested systems capable of rapid deployment which are ready for use prior to any incident occurring. The following mechanisms should be considered:

• face to face communication with affected individuals or groups e.g. patients, staff, general public at public meetings;
• the establishment of a special helpline provided by NHS 24;
• letters or fact sheets provided directly to patients, staff, members of the public in an affected healthcare setting or community;
• information in the form of statements, press releases, interviews and briefings for the print and electronic media (see section below);
• specially designed information leaflets to be distributed at appropriate points;
• briefing key members of the public such as head teachers, MSPs, councillors, members of local health council.

122. Wherever possible standard templates for communicating with the general public and the media should form part of planning for more common or potentially dangerous types of incidents. They should include standard press releases and 'question and answer' information sheets. These should require minimal customisation during incidents to facilitate speedy communication.

123. NHS 24 may be able to provide more extensive support in a major public health incident based on the organisation's contact centre network, technology, voice infrastructure and contingency arrangements.

124. In some types of incident, private or public sector organisations implicated as probable sources of the exposure to a hazard will have existing lines of communication to their customers, clients or patients. At times the organisation may form part of the IMT e.g. Scottish Water as described in the Scottish Waterborne Hazard Plan. Use of these lines of communication can often facilitate advising the public on how to reduce risks and to implement control measures to prevent exposure e.g. not drinking the water. In these circumstances the IMT should liaise with the organisation in employing its knowledge and resources to communicate with public about risks. The IMT should co-ordinate the content and tone of any messages and how these should be disseminated.

125. NHS Boards should have in place mechanisms to establish special helplines promptly e.g. via NHS 24. In some incidents the public will look to contact a specific company or agency to obtain information about their services or products. In these instances, the IMT should liaise closely with the organisation about the measures it is taking to deal with customer enquiries while recognising that the mechanisms for doing so are best left to the company involved. It should be made clear however that the central public health message is the responsibility of the IMT.

126. The IMT should maintain an overview of all communications to ensure that there are no contradictions in their content or tone. The IMT Chair, or delegated deputy, has overall responsibility and should agree any suggestions/changes to communications prior to their being distributed for comment or release.

Media handling

127. The considerable extent of public, press and political interest in recent incidents highlights the importance of paying careful attention to this aspect of incident management. There is a need, in large-scale incidents, for a clear and proactive approach to media management and public relations especially by NHS Boards. In view of the crucial interface with the media, media management should form an essential part of incident plans. Actively engaging with the media and providing accurate and timely information may prevent inaccurate reporting and negative outcomes.

128. For all national and large scale incidents. NHS Boards should bear in mind that there will be a need to co-ordinate media activity closely with the Scottish Government communications team and partner agencies. SGHD will often refer media to the local NHS Board for detailed information but it is important that key messages are co-ordinated.

129. There are two important roles that require to be fulfilled, that of media liaison and that of acting as spokesman for the IMT.

130. To fulfil the first role, a member of the NHS Board's communications team should liaise with the media to ensure that the information communicated to them is consistent and to organise arrangements for press briefings, interviews etc. He/she should be the identified communication team member acting in this capacity on behalf of all organisations involved in the IMT. The IMT Chair, or delegated deputy, would usually fulfil the second role i.e. be the 'public face' of the IMT. There may be situations when the communications team fulfils both roles. If other professional opinions are sought from individual IMT members, these should not be given without the agreement of the IMT Chair and full liaison with the communications team. Whenever possible those from other organisations answering media enquiries should be members of the IMT.

131. In some instances it may be desirable for other organisations represented on the IMT to respond to press enquiries which specifically relate to their operations or legal responsibilities. Arrangements should ensure that such organisations can respond promptly to such enquiries without straying from, or indeed contradicting the core message about the public health risks and the measures being taken to reduce them.

132. To avoid confusion, a common data set (e.g. on number of cases and their clinical status) and a timetable for its compilation and issue to the media should be agreed by the IMT. Decisions about media briefing, and the issuing of press statements, should be made at each IMT meeting. In doing so, careful consideration should be given to:

• background briefing material, e.g. role of the IMT, the general nature of the hazard or threat, what is known, and important facts which may not be known;
• the implications of releasing the information;
• the implications of the timing of the release;
• the importance of presenting complex information in simple language;
• and the different requirements of the print and broadcast media; and
• consideration given to use of more immediate social communication tools

133. All press statements issued should be copied to the press offices of all organisations represented on the IMT, the SGHD and other relevant organisations.

Audit, evaluation and documentation

134. A recurrent theme with public health incidents is the need to learn from experience.

This involves three key components:

• A formal IMT debriefing on the management of the incident with a view to including lessons learnt in an IMT report. The debrief should take place as soon as possible after the incident;
• An assessment of the performance of statutory agencies in managing public health incidents; and
• An evaluation of the effectiveness of incident management arrangements in protecting the public health.

135. IMTs both during and in the debriefing following an incident should use criteria jointly agreed with their partners (Annex J) to assess and report on their own performance to the NHS Board clinical governance committee in managing the incident and the appropriateness of current plans. Recommendations on how these can be improved should be included in the IMT report.

136. The IMT should prepare a report and the IMT Chair has the overall responsibility for its production. The IMT report should be the product of agreement of all full members of the team. If this is not possible, the report should note areas of disagreement. Officers of the constituent agencies in the IMT who were not IMT members should not edit the report after its production. A template for the report is provided in Annex K with a standardised dataset in Annex L. The report should, in addition to describing the incident, consider the effectiveness of the investigation and the control measures taken. The report should include recommendations to prevent further incidents and improve the handling of further incidents and may include an identified need for further research.

137. Based on the results of the investigation, risk assessment and debriefing, the IMT should formulate targeted recommendations with timescales. The IMT Chair should ensure that the report and specifically the section dealing with the recommendations, is communicated to the targeted organisation. NHS Boards are responsible for monitoring whether IMT recommendations are followed up. The NHS Board to which the IMT is accountable should ensure that there is a response to the recommendation from that organisation for its implementation. If it has statutory responsibilities, it must reply to the NHS Board laying out its response to the recommendation.

138. It may in some instances be necessary to delay or limit the circulation of the final report pending legal action. In such cases legal advice should be sought.

139. The IMT Chair, in discussion with the IMT, should determine the most appropriate format of the IMT report. A full IMT report should be written in the following situations:

• Significant lessons identified that should be shared locally or nationally;
• Actions required by other agencies to address problems identified;
• Novel infection, sources or pathways of infection;
• High mortality or morbidity;
• Changes required in guidance; or
• Significant public or political interest.

140. If the IMT Chair does not consider a full report is necessary a summary of the incident should be provided in an SBAR (Situation, Background, Assessment, Recommendations) format. SBAR template is provided in Annex M. The SBAR format can also be used for updates during the incident.

141. IMT reports should be sent for formal review to a NHS Board meeting or a NHS Board Committee e.g. Clinical Governance Committee. The reports should also be sent to HPS and made available to appropriate individuals, the Local Authority, and the SGHD or other SG Directorate with responsibility for aspects of the outbreak/incident. Other relevant regulatory agencies should receive a copy.

142. The NHS Board is responsible for approving an action plan to follow up the recommendations contained in the report, (where this is required). The action plan should be appended to the copies of the report submitted to the SGHD. If a recommendation has major policy implications or if the response from the agency to which an action is recommended is deemed by the NHS Board to be inadequate, the NHS Board should inform SGHD who will review the issue further.

143. In addition to an IMT report, all relevant incidents should be summarised in the appropriate standard summary form for submission in timely fashion to HPS for the purposes of incident surveillance.

144. The role of HPN in supporting collation of lessons learnt and sharing is described in Annex F.