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.