COMMUNITY CARE TRUST (SOUTH DEVON) LTD
INCIDENT REPORTING
POLICY No. CCT028
POLICY STATEMENT
The Trust is committed to ensuring that it responds promptly and efficiently to all
adverse incidents and near misses. The policy focuses on increasing awareness
both of the nature of incidents and to the appropriate response and action to be taken
in the event of its occurrence. In addition it will ensure that the appropriate
mechanisms for reporting incidents are in place.
All incidents should be reported as soon as possible whilst ensuring the appropriate
action has been taken to ensure the immediate safety of those involved.
Serious incidents must be investigated following the CCT113 Serious
Untoward Incidents policy.
POLICY AIMS
This policy aims to prioritise the safety of everyone within the Trust including people
who use the Trust’s services and workers (both paid and unpaid), whilst working
within the law and relevant legislative frameworks without judgement.
Any learning taken from themes and trends in incidents will be fed back to staff within
the particular service where the incident occurred and will also inform the senior
management team who will ensure appropriate action is taken to reduce the risk of
such incidents occurring again.
AUDITING AND MONITORING
All incidents will be recorded on CCT Incident Report Forms (found on the CCT
shared drive). It is the responsibility of the Service Manager to ensure actions are
taken to reduce the risk of recurrence. All incident reports are copied to the
Governance Lead.
If the incident is identified as a Serious Untoward Incident or further investigation is
required to prevent a recurrence, the Service Manager will implement an
investigation following the Serious Untoward Incident policy.
A monthly audit of all incidents is presented to the Governance Committee to review
trends and identify good practice through shared learning.
TRAINING
All Staff: An introduction to incident reporting is included in the CCT induction
programme. Incident reporting training is provided to existing staff through team
meetings and clinical governance groups
INCIDENT REPORTING PROCEDURE
INCIDENT occurs
People/area made safe or appropriate
assistance/first aid provided.
Senior member of staff informed
If incident is
considered to be a
SUI then follow SUI
procedure
Member of staff
completes Accident /
Incident report form
Line manager checks that
all necessary actions
have been put in place
If incident requires
reporting to an external
agency e.g. RIDDOR,
CQC, Safeguarding
Form sent to
Governance Lead at
The Haven
Form received by Governance Lead at
The Haven
Information input on database system
Monthly report produced for
the Clinical Governance
Team
Quarterly report
produced for
Commissioners
RISK SCORING MATRIX
The Risk Scoring Matrix enables the person who has discovered an incident to
establish whether it falls within the parameters of a Serious Untoward Incident (SUI)
and to act according to the SUI policy.
Likelihood / Probability
1 = Unlikely
2 = Low
3 = Moderate
4 = Likely
1-24%
25-49%
50-74%
75-99%
5 = Certain
100%
May occur but doubtful / improbable
Could occur at some time but rare / exceptional
Might occur at some time (fairly likely)
Will occur in most circumstances
(likely/probable)
Expected to occur in most circumstances (no
doubt)
Consequence / Severity (Further guidance appears on page 4 of this policy)
1 = No harm / near miss
No harm / damage, negligible risk to finances /
business or reputation
Minor harm / damage (first aid), minor financial
Loss
Moderate harm / damage (medical treatment),
death confirmed as natural causes, moderate
financial, business / reputation loss
Major harm / damage (excessive injury),
excessive financial / business / reputation loss
Unexpected / multiple deaths, intolerable
financial / business / reputation loss
2 = Minor
3 = Moderate
4 = Major
5 = Catastrophic
We calculate the level of risk of a incident by multiplying likelihood by
consequence (below). Those areas that are calculated as a high risk are
Serious Untoward Incidents and fit under the umbrella of the SUI policy
Unlikely
Low
Moderate
Likely
Certain
No harm / near miss
1
2
3
4
5
Minor
2
4
6
8
10
Moderate
3
6
9
12
15
Major
4
8
12
16
20
Catastrophic
5
10
15
20
25
Minimal
Risk
1-2
Low
Risk
3-6
Moderate
Risk
8-12
High
Risk
15-25
REPORTABLE INCIDENTS
Whilst it is not possible to cover every eventuality, the following incidents must
always be reported. For ease of reference they have been loosely grouped into:
people using the service; information governance; accident/damage/theft/loss; and
other.
Person using services
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Medication incidents / errors / near misses
Slips/trips/falls of a person using a service
Absence of a person using services
Self-harm
Incidents involving alcohol or misuse of drugs
Safeguarding concerns
Incidents involving emergency services
Information Governance




Breach of confidentiality
Loss of person identifiable data
Incidents relating to a person’s records, including unavailability
Breach of security
Accidents / Damage / Theft / Loss
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Accidents involving any person on CCT premises
Incidents involving any vehicle on CCT premises
Theft of property: CCT, staff or person using services
Loss of property: CCT, staff or person using services
Damage to CCT property: premises; fixtures; equipment etc
Injury or ill-health suffered as a result of handling inanimate object
Contact with bodily fluids – needlesticks
Contact with harmful chemicals or spillages
Fire: actual / potential or false alarm
Other


Expression or act of violence or aggression
Procedure or protocol related incidents, including failure to follow
Date of last review: September 2011
Version number:
03
Date of next review: September 2014
Signature ………………………………
Consequence examples for guidance
Consequence
Injury / Illness
Person who is
supported by
CCT’s Experience
Single resolvable
problem in person’s
experience
1 (No harm /
near miss)
Illness or injury
not requiring
intervention
2 (Minor)
Minor injury or ill
health – First Aid
or no treatment –
No incapacity
Person’s
experience
temporarily
unsatisfactory –
rapidly resolved
3 Moderate
Significant injury
or ill health –
medical
intervention
necessary. Some
temporary
incapacity
Patient outcome or
experience below
reasonable
expectation in one
or a number of
ways
4 Major
Major injuries or
long term
incapacity or
disability
5 Catastrophic
Death or major
and permanent
incapacity /
disability
Patient outcome or
experience
significantly below
reasonable
expectation across
the board
Totally
unsatisfactory
outcome for the
person
System or Project
Complaint / Claim
Financial Loss
Adverse Publicity
Resolvable
problem with
peripheral system
or project
Resolvable
problem with
important system or
project. Partial
failure of peripheral
system or project
Resolvable
problem with critical
system or project.
Partial failure of
important system or
project. Failure of
peripheral system
or project
Partial failure of
critical system or
project. Failure of
important system or
project
Low value claim
handled by ex
gratia payment
£0-£500
Awareness limited
to individuals within
the organisation
Justified complaint
peripheral to
clinical care (e.g.
car parking access)
£500-£5,000
Justified complaint
involving lack of
appropriate care, or
below excess claim
£5,000-£50,000
Coverage limited to
elements within the
organization (e.g.
Trade Unions) and
/ or some external
stakeholders
Coverage
throughout
organization and /
or some public
coverage
Above excess
claim. Multiple
justified complaints
£50,000£1,000,000
Extensive local
coverage and
widespread NHS
coverage
Failure of critical
system or project
Multiple claims or
single major claim
£1,000,000 +
Nationwide multimedia coverage
What is a Serious Untoward Incident?
Definition:
Incidents
requiring
immediate action
by the person
who discovered
the incident
Incidents that
require reporting
under this policy
Situation is a SUI
requiring action
under the terms
of this policy with
a matrix score of:
Vulnerable Adults and Children
Health and Safety
Impact on CCT
Any situation whereby a vulnerable
person is abused verbally, physically,
psychologically, sexually, neglectfully,
financially, discriminatorily, or
institutionally.
Any incident that involves a person or
group who / which is engaged in an
activity associated with the CCT. This
may include contractors, trainers, outside
agencies or relatives / visitors. It may
also include members of the public.
 Violent behaviour
 Infections e.g. HIV
 Accidents
 Deaths
 MRSA / Stomach bugs
 Notifiable communicable
diseases
 Theft
 Self harm/ overdose
 Unexplained absence
 Trips/ falls/ faulty equipment
 Fire and flood
 Outbreaks of infection
 Major incident involving emergency
services
 All of the above
 Any near miss with regards to patient
safety
 Any incident which has major or
catastrophic consequences
Any incident that reflects negatively on
how the organisation is perceived in the
outside world. This could impact on
capacity to deliver the service.
15 or above
15 or above
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Violation of an individual’s human
or civil rights by an act or failure
to act.
Abuse resulting in significant
harm to or exploitation of the
person subjected to it either by a
single or by repeated acts.
All Instances where potential
abuse of trust may have led to an
inappropriate act.
The scoring matrix does not apply
as all situations where there is a
suspicion of an untoward incident
concerning a vulnerable person is
a Serious Untoward Incident


Any Safeguarding Adults or
Children issue
Violent behaviour that is known to
people other than those involved.
Inappropriate behaviour by anyone
associated with CCT which would
be of interest to the media or
gossip.
Reportable CD errors

All of the above
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