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1.5.5 Critical Incident Reporting

Contents

  1. Introduction
  2. Culture
  3. Definition
  4. To Whom should Critical Incidents/near Misses be Reported
  5. Action Following Reporting
  6. Links with Other Policies and Procedures


1. Introduction

In order for this to be a learning organisation it is essential that the Head of Service is promptly advised of serious or critical incidents (or “near misses”). This is to ensure that the learning from the incident can be reviewed and disseminated appropriately throughout the Department.

If this does no happen we are deprived of the opportunity to learn, to improve the service and reduce risks for service users. It also makes the division vulnerable to unexpected public criticism and litigation.


2. Culture

Learning does not take place in a blame culture. Errors cannot be prevented altogether and they occur for a variety of reasons and in a context (many factors contribute). Punishing people does not, of itself, make errors less likely.

The Division therefore encourages openness and discourages blame. There will, however, be occasions when action, including disciplinary action, must be taken in order to maintain standards and protect service users.


3. Definition

What is a critical incident?

  • Death of a service user
  • A service user suffers serious harm (sexual or emotional harm as well as physical injury)
  • A “near miss” – either of the above could have occurred but was averted.
To require reporting under this procedure there should be at least the possibility that the event was due to a failure on the part of an individual or system within the division.


4. To Whom should Critical Incidents/near Misses be Reported?

  • Head of Service
  • Operations Manager
  • Service Manager Child Protection & Quality Assurance
A brief report should be sent setting out a brief history of the case and the reason why it is thought that the criteria for conducting a review of the case are met.


5. Action Following Reporting

The Head of Service will determine whether a review of the case or the incident is required and if so its scope and the timescale for completion. Other relevant managers will also be informed. If a review is required it will usually be conducted by the Service Manager CP/QA or a member of his team. The process will involve:

  • A review of any paperwork
  • Interview of staff involved
  • Analysis of the root cause of the failure
  • Report including action plan to Head of Service
  • Prompt dissemination of findings to relevant staff
Lessons learnt from these reviews and other quality assurance work (e.g. file audits) will be disseminated on a regular basis.


6. Links with Other Policies and Procedures

Other processes may run alongside this one (e.g. complaints) and so care must be taken to coordinate action and to keep those involved fully informed.

Dave Seal
Service Manager CP/QA
July 2005

End