Patient safety and experience

Serious Incidents

The CCG is committed to ensuring that we commission services that provide high quality care with patient safety as one of its fundamental principles. It is therefore essential that the CCG and all of our providers have effective processes in place to allow staff to report incidents when patients have, or could be harmed.

There is no definitive list of events/incidents that would constitute a Serious Incident and every incident is therefore considered on a case-by-case basis using the definitions detailed below:

• Acts and/or omissions occurring as part of NHS-funded healthcare (including in the community) that result in:
  • Unexpected or avoidable death of one or more people. This includes;
    • suicide/self-inflicted death; and
    • homicide by a person in receipt of mental health care within the recent past
  • Unexpected or avoidable injury to one or more people that has resulted in serious harm
  • Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent;
  • the death of the service user; or
    • serious harm
  • Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where;
    • healthcare did not take appropriate action/intervention to safeguarding against such abuse occurring or
    • where abuse occurred during the provision of NHS-funded care
• An incident (or series of incidents) that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of healthcare services, including (but not limited to) the following:
  • Failures in the security, integrity, accuracy or availability of information often described as data loss and/or information governance related issues, including cyber security (See Section 5.1.8)
  • Property damage
  • Serious breach/concern
  • Incidents in population-wide healthcare activities like screening and immunisation programmes where the potential for harm may extend to a large population.
  • Inappropriate enforcement/care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act Deprivation of Liberty Safeguards (MCA DOLS)
  • Systematic failure to provide an acceptable standard of safe care (this may include incidents, or series of incidents, which necessitate ward/unit closure or suspension of services)
  • Activation of Major Incident Plan (by provider, commissioner of relevant agency)
• Major loss in confidence in the service, including prolonged adverse media coverage or public concern about the quality of healthcare or an organisation.

Through investigation of incidents and analysing the root cause, there is an opportunity for the CCG and/or our providers to learn lessons and implement actions to reduce the risk of an incident recurring and ultimately improving patient outcomes.

The reporting of incidents, and the subsequent learning, is therefore regarded as positive by all staff, including those employed by provider organisations, and NHS England has provided a clear framework about the declaration and management of Serious Incidents.

The CCG’s SI processes for reporting and managing SIs relates to all services commissioned by the CCG and staff employed directly, and working on behalf of the CCG. We therefore expects all commissioned organisations that provide NHS funded healthcare to incorporate the requirements of the CCG’s SI policy into their own organisational policies, as per the requirement within the NHS Standard Contract.

Should you have any concerns about an incident that you are a family member / friend has been involved in, that you feel it not be treated appropriately, you can raise these directly with the providers patient service/complaints department, such as PALS for example.