Managing Health at Work Partnership Information Network (PIN) Guideline

MANAGING HEALTH AT WORK

APPENDIX 9.F
Checklist for a formal investigation

This process has been drawn up for clinical settings, but the same principles should be adapted for non-clinical settings.

Stage 1

An initial meeting should take place where possible within 72 hours of the incident, in order to:

• review the circumstances surrounding the incident;

• support those involved in the incident (staff, patients, relatives, visitors etc);

• discuss and agree if there is a need for a formal review; and

• set a date for the formal review.

This meeting should include the service manager and staff involved. In a clinical setting this meeting would also include the patient's GP or consultant.

Questions to be raised at stage 1:

1 Who will chair the formal review?
2 Who will make a record of the review?
3 What happened?
4 Was a staff member hurt? If so, what was the extent of the injury/ies?
5 What help was given to the staff members on duty during the incident?
6 Was a patient hurt? What was the extent of the injury/ies? What action was taken?
7 Have relatives been informed?
8 Were any visitors or non-Trust staff involved?
9 Was an incident form completed and a record made in the person's records?
10 Was the duty doctor and/or the person's consultant informed?
11 What is the person's care plan/safety care plan? Was it implemented? Did it work? Does it need to be reviewed?
12 Are there any service/resource/training implications?
13 Were other agencies involved? If yes, invite them to the stage 2 meeting.
14 Has the Lead Clinician/Nurse or Head of Clinical Services been alerted of any concerns about possible press response to the incident?
15 Is there a need for a stage 2 meeting? If yes, request Lead Clinician/Lead Nurse or Head of Clinical Services to nominate a Chairperson and inform the Organisation Audit Secretary.
16 Who should receive a copy of the record of the meeting?

At the end of the meeting, the convenor of the Stage 1 review is responsible for:

• notifying the General Manager, Lead Clinician/Nurse or Head of Clinical Services of any immediate actions that need to be taken because of the incident; and

• sending an initial report to the Clinical Risk Manager.

Stage 2

1 The stage 2 meeting should take place within 4-6 weeks of the incident.

2 A senior clinician or other appropriate person will chair the meeting, which will be recorded by the Clinical Office/Audit Secretary. It should involve the staff directly involved in the incident plus significant others who have responsibility for that part of the service or to the patient involved.

3 The minutes of the stage 1 meeting should be available and form the starting point for discussion which will expand to cover the following:

• events leading up to the incident;

• what happened during and after the incident;

• person's care plan;

• number of staff on duty;

• level of staff on duty;

• any shortages that may have contributed to the incident;

• availability of staff at the time of incident;

• environmental factors;

• equipment failure;

• needs of other patients present during the incident;

• information and support needs of the family;

• support needs of staff, including legal advice or representation, if appropriate;

• any service/resource/training implications;

• information to go to GP;

• report to Clinical Risk Manager;

• contacting the Central Legal Office if required; and

• in the case of deaths, considering whether a Fatal Accident Inquiry is likely.

4 A record of the discussion and the outcomes of the review must be forwarded to:

• the Clinical Board, where actions are identified; and

• the Clinical Governance Group, to ensure a continuous audit of such incidents.

The Audit Secretary will retain a copy to maintain a central file of all serious incident reviews.

Stage 3

The minutes of the reviews will be audited annually to:

• identify any repeated issues;

• update the review process itself; and

• adapt standards as necessary.