Incident Reporting Policy
and Procedures
Document Type
Incident Reporting Policy and Procedures
Author
Chief Executive
Owner (Dept)
Services and Development
Date of Review
April 2014
Version
3
INCIDENT REPORTING PROCEDURE
List of Contents
Page
1.
Policy
2
2.
Background
2
3.
Definitions
2
4.
Scope
3
5.
Reference Documents
3
6.
Responsibilities
3
7.
What should I report?
4
7.1
7.2
7.3
7.4
7.5
7.6
4
5
6
7
7
8
8.
A Fatality
Minor injury / Major injury / Over-7-day injury accidents
A near miss to injury
A Specific Notifiable Disease
A Dangerous Occurrence
People category
How do I make a Report?
8
8.1.
10
The requirements under the Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations 1995 (RIDDOR)
Supporting document to be used with this policy and procedure




Example of an Incident Report Form
Example of a Summary Information Sheet
Example of a Witness Statement Form
Incident Reporting Flow Chart
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
1. Policy
In accordance with the Aims and Objectives of The Mungo Foundation’s Health and
Safety Policy, our incident reporting procedure considers everyone that may come
into contact with our work activities or premises. Employees are expected to cooperate with their Employer to ensure that statutory obligations are met. Failure to
comply may result in prosecution for The Mungo Foundation (TMF), of individual staff
and/or disciplinary action being taken against Employees.
This policy defines the processes, identifies those with responsibility and provides
guidance for the internal and external reporting for Accident and incident reporting
and investigation.
2. Background
Our reporting procedures have been reviewed and amended accordingly to:

Provide a comprehensive understanding of incident reporting and ensure we
report incidents, effectively

Minimise the delay in the reporting of incidents and to encourage the
immediate implementation of corrective and preventative measures
 Comply with the statutory duties set out in the “Reporting of Injuries, Diseases
and Dangerous Occurrences Regulations 1995” (RIDDOR), the Social Security
(Claims and Payments) Regulations 1979 and the Data Protection Act 1998.
3. Definitions
3.1
An Incident – all circumstances leading to or causing a work-related accident,
work-related ill health, a near miss situation, specific types of disease or
dangerous occurrences. or ‘‘a significant event which demands a response
beyond the routine’
A near miss is a type of incident - “An event or occurrence which but for skilful
management or a fortunate turn of events, would have led to harm, loss or damage.”
3.2
A Work-Related Accident – ‘any event that results in injury or leads to ill-health
or people, or damages equipment, property or materials but where there is
harm’ source HSE
3.3
A Specific Notifiable Disease – are related to particular work activities. For
example you need to report a case of infection only when you can reliably
attribute it to the work that a person does. Infections which could have been
acquired equally easily at work or in the community are not reportable.
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
3.4 A Dangerous Occurrence – is a specified event which may not result in a
reportable injury, but has the potential to do significant harm e.g. the collapse,
overturning or failure of load-bearing parts of lifts and lifting equipment etc.
3.5 Safeguarding Incidents - the Adult Support and Protection (ASP) Act states harm
includes all harmful conduct/incidents and in particular includes;




Conduct or incidents which cause or could cause physical harm or danger
(medication error, physical assault, poor support and care, neglect etc)
Conduct which causes psychological harm (for example by causing fear,
alarm or distress)
Unlawful conduct which appropriates or adversely affects property, rights or
interests (for example: theft, fraud, embezzlement or extortion)
Conduct which causes self-harm
4. The scope of this policy?
The Mungo Foundation recognises that it has a legal obligation to report certain
accidents, specified diseases and dangerous occurrences to the enforcing
authorities. There is also a requirement to report all incidents, including accidents and
any near - miss situation, to ensure that there are positive steps taken to prevent a reoccurrence.
The scope of this policy is to ensure that all Employees within The Mungo Foundation
clearly understand the process of and their role within the Accident and Incident
Reporting and Investigation process.
5. Reference Documents







Health and Safety Policy and procedures
Health and Safety forms, risk assessments and documents
Incident reporting forms and guidance
De-briefing forms
Care Act, Care Standards and guidance on notifiables
Adult Support and Protection procedures and reporting protocols
The Mungo Foundation policies and procedures
6. Responsibilities







Chief Executive
Directors
Health and Safety Manager
Area Managers
Managers
Administration Team
All Employees
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
7. What should be Reported?
In addition to the following categories, The Mungo Foundation has decided that an
Incident Report Form must also be completed where incidents occur in relation to
support and care matters, including those who use our services. This includes, but is
not exhaustive to- medication error, self injurious behaviour, incidents of harm or
potential harm, behaviour out of character, assault on a service user by another
service user, mis-use of medication, loss or theft of monies or belongings, unplanned
restraint or physical intervention of a service user. An incident pick list accompanies
the Incident Report Form and details the types of incidents that tend to be
reported/occur in the work place and indeed a social care environment.
It is noted that the management and reporting of Incidents will often require the
notifying of incidents to external authorities such as Medical Professionals, Police,
Care Inspectorate/ Regulatory Bodies, Social Work and Safeguarding Teams.
Direction and guidance must be sought from line management where external
notification is required or indeed where there is any uncertainly around notifying.
7.1 A Fatality
In the event of a fatality, Medical assistance, the Police Authorities and as
appropriate, the Enforcing Authority either the Environmental Health Department or
Health and Safety Executive must be contacted immediately (see website for health
and safety enforcement listings – www.themungofoundation.org.uk/staff/health and
safety/H&S Information).
In addition, the following personnel or authority must be informed as soon as possible:
For Services and Projects
 The Care Inspectorate;
 The Care Manager;
 The Mental Welfare Commission;
 The Registered Manager;
 The Area and/or on-call Manager;
 The Health and Safety Manager.
For offices/workshops
 The Senior or “on-call” Manager;
 The Health and Safety Manager.
During investigations, on-site Managers and/or other employees may be required to
provide details of the events leading up to, during and at the time of the fatality.
The Health and Safety Manager will be available for advice and assistance during
the course of any necessary investigation.
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Issue Date: July 2013
Responsibilities:
 Employees: Must seek immediate medical assistance, contact the Police
Authorities and the Enforcing Authority (Environmental Health Department or
Health and Safety Executive);

Managers: Must alert their own Area Manager who will provide assistance and
guidance to ensure the appropriate formal reports are completed. Guidance
and direction from The Health and Safety Manager should also be sought in
instances of completing HSE reports

Managers: Should be cognisant of the potential obligation to notify external
agencies such as,
Care Inspectorate, Safeguarding Teams or
Commissioning/contracts Teams, Mental Welfare Commission, HSE “notification”
requirements involving service users
For the purpose of clarity, where an individual dies as a result of an end of life
condition or the death has been expected, there is no duty on staff to report the
death to the HSE - all deaths however must be reported to medical professionals
(GP/NHS 24) at the time of death, as well as notified to the Care Inspectorate and
Care Manager Local protocols around informing family and next of kin should also be
followed.
7.2 Minor / Major / Over 7 Day Injury Accidents
In the event of a minor or major injury accident medical assistance should be
considered.
The Manager will conduct an investigation to establish the cause of the accident,
what treatment was given if any, and what action is required to prevent a similar
occurrence.
An over 7 day injury (previously over 3 days) is one which results in the injured person
being away from work or unable to do the full range of their normal duties for more
than seven days. This includes any days they wouldn’t normally be expected to work
such as weekends, rest days or holidays not counting the day of the injury itself (see
RIDDOR Supplement for further information).
Should a minor injury further result in absence from work for more than seven days or
the incapacity of that person to conduct their normal work, then details must be
forwarded to the Health and Safety Manager.
Responsibilities:

Employees: must report incidents to their Line Manager or “on call” Manager
before the end of their working shift or before leaving the work setting.
Where it is not possible or not practical to report an incident in this way then the
employee or someone acting on their behalf, must contact the Line Manager
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Issue no. 3
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the following day and give details of the incident. Please note: Failure to report
“Lost time / time-off work” accidents will result in normal absence procedures
applying.

Managers, Employees or their Representatives: Must record details in the
Incident Report Form

Managers: Must ensure that all reported incidents involving service users and
other non-employees, are also recorded;

Managers: Must (without delay) report major and over 7 day injury accidents to
the Health and Safety Manager by telephone

Managers: Should refer to Procedures for “notification” requirements involving
service users, members or clients.
7.3 A Near Miss
A near miss” can be described as “an unplanned, uncontrolled or unexpected event
that could have resulted in loss of some kind”.
In essence, it is often only a matter of luck as to whether or not an untoward event
resulted in loss or not. In health and safety it is considered more prudent to attempt to
control the untoward event before the injury or near miss occurs.
From a preventive viewpoint, it is often the same immediate, underlying and root
causes that result in either the near miss or the injury. Therefore, near misses can be
seen to be preventive opportunities.
The Mungo Foundation’s proactive approach to accident prevention is to
encourage its employees to report any "near-miss" event - an accident that but for
slightly different circumstances, could have had a different, more serious outcome.
Some examples are: “The wheelchair toppled slightly over as the vehicle turned the
corner” and “Whilst cooking late at night the cooking utensils and food contents were
burned setting off the smoke detector”.
When reporting a near miss event it may be difficult to complete certain sections of
the form therefore where there has been a reasonable attempt to provide
information, part-completed forms will be acceptable.
Responsibilities:

Employees: Must report near misses to their Line Manager

Managers: Must record as much detail as possible when completing the
incident Report Form.
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
7.4 A Specific Notifiable Disease
If a doctor notifies us that our employee suffers from a reportable work-related
disease we must send a completed report form to the enforcing authority
(see website for enforcement authority listings
www.themungofoundation.org.uk/staff/health and safety/H&S Information)
Responsibilities:

Managers: Must report any doctor’s notification to the Area Manager and
inform the Health and Safety Manager

Managers: should refer to Procedures for “notification” requirements involving
service users
7.5 A Dangerous Occurrence
Although such events are rare, there need not be any personal injury sustained for a
Dangerous Occurrence to be classified. Where it is suspected that a Dangerous
Occurrence has occurred, the Health and Safety Manager and local Management
must be informed immediately. It is important to note that the person responsible for
reporting a Dangerous Occurrence is the Manager or the person in charge of the
work setting/premises. Therefore, if a contractor is working on behalf of The Mungo
Foundation and they affect the Dangerous Occurrence, The Mungo Foundation will
be required to report the incident, not the contractor.
Responsibilities:

Employees: Must report a dangerous occurrence to their Line Manager;

Managers: Must inform the Health and Safety Manager;

Managers: Must complete the Incident Report Form; even if there have been
no injuries;

Managers: Should refer to Procedures for “notification” requirements involving
service users.
In addition to the aforementioned guidance, further information can be obtained on
the categories of reportable accidents, specific diseases and dangerous occurrences
from the The Mungo Foundation website
(www.themungofoundation.org.uk/staff/health and safety/H&S Information) or by
contacting the Health and Safety Manager.
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
7.6 People Category
Incident report forms may be completed for the following groups of people:

Employees of The Mungo Foundation, Service Users, members, clients,
families, carers

Contractors, Members of the Public, Visitors

Trainees, Work Experience Students, Volunteers.
8. 1 How do I Make a Report?
An employee of The Mungo Foundation involved in an incident, must record the
details on part 1 of the Incident Report Form. Where they are unable to e.g. through
an injury etc they can ask a representative or their Line Manager to complete the
details for them. The Line Manager should confirm that the written report, clearly
states the events leading up to, at the time of and after, the incident. The line
manager should also ensure that the person completing the form details those who
have been involved in or who have witnessed the incident. Part 2 must be completed
by the responsible Line Manager - this section provides opportunity for the incident to
be defined using The Mungo Foundation’s Incident Pick list. Identifying the nature and
type of incident is a key aspect in trend analysis and overall corrective/preventative
management of incidents. This section also requires the Line Manager to record what
management support or guidance has been taken in response to the incident.
A copy of Part 2, alongside Part 1 of the Form must be forwarded to Head Office for
the attention of Catherine Sloey (PA to the Chief Executive) and the Area /Senior
Manager.
The Area Manager and /or The PA to the Chief Executive will ensure that the Incident
Report Form is forwarded to The Mungo Foundations’ Health and Safety Manager
where the incident relates to specific Health and Safety at work matters, and where
Health and Safety Management guidance, risk assessment and expertise is required.
Part 3 must be completed by the relevant Area Manager or Senior Manager/Director
(where the incident does not relate to care provision and, for example, relates to the
office environment or staff. A copy of Part 3 of the Incident Form must be forwarded
to Head office for the attention of Catherine Sloey.
Original copies of the Incident Form will be held in the local Incident Folder. Incident
forms for the prior year will be archived in accordance with The Mungo Foundation’s
policy.
Forms can be posted (recorded delivery) or submitted to Head Office electronically
(scanned or faxed).
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Issued by: Chief Executive
Issue no. 3
Issue Date: July 2013
All incident records, including supplementary sheets and/or witness statement forms,
must be retained within the scope of the Data Protection Act 1998 (refer to website
for further information www.themungofoundation.org.uk/staff/health and safety/H&S
Information)
Part 4 must be completed by both the Area/Senior Manager and the Line Manager
upon completion of the incident and of any investigations or critical reviews that
have been carried out. This section will detail the actions taken by management and
record any measures that have been put in place. It should also detail how measures
will be implemented and reviewed, for example - Staff training, agreed regular review
and monitoring of a service users care plan, adjustments to environment, purchase of
specialised equipment
Summary
Note 1: the member of staff /person reporting the incident must complete Part 1 of
the Incident Report Form. A copy of the from should be forwarded to Head Office as
soon as possible and within 3 days for the attention of the Area Manager and
Catherine Sloey (PA to the Chief Executive). The person reporting the incident must
also notify their line manager or on call manager as soon as possible of the incident
Note 2: the line Manger must complete Part 2, of the Incident Report Form providing a
definition of the incident and management steps taken. A copy of the form must be
forwarded to Head Office as soon as possible and within 3 days for the attention of
the Area Manager and Catherine Sloey
Note 3: the Senior/Area Manager/PA to the Chief Executive will ensure that The
Health and Safety Manager is provided with copies of all Incident Report Forms that
require Health and Safety Management overview, guidance or input
Note 4: the Area Manager/Senior Manager must complete Part 3 of the Incident
Report Form, in relation to an incident report relating to their services or area. This
must be completed detailing the Senior Manager’s response to the incident. A copy
should also be provided to Catherine Sloey at Head Office for central filing.
Note 5: both the Line Manager and Area/Senior Manager must complete part 4, of
the Incident Report Form, detailing the conclusion of the incident and
actions/measures taken at a management level. A copy of this will be forwarded to
Catherine Sloey, PA to the Chief Executive at Head Office for central filing. The
management process should take between 7 – 28 days.
Note 6: the Employee and/or Line Manager must ensure that relevant bodies are
notified of the incident should the incident be a notifiable
Note 7: On request, external agencies and commissioning authorities are permitted to
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Issue no. 3
Issue Date: July 2013
receive copies of the Incident Report Forms and details of any investigations carried
out. When requests are made staff must direct the request to the Area Manager to
determine whether information can be provided.
Note 8: The Incident Report Form meets the standards of the Department of Works
and Pensions. There is no requirement to implement an additional accident book.
Responsibilities:

Managers must make a reasonable effort to contact the person(s) involved in
the incident to ensure completion of the incident report form and to finalise
their investigation into the incident.

For the purposes of legal enquiries, Managers must ensure that all forms are
retained for 5 years.

Managers must ensure that the original documents are submitted to the Health
and Safety Manager within 10 - 15 days.

Area Managers must ensure any serious or recurring financial irregularities are
reported to the Director of Finance on receiving report from.
8.1 The legal Requirements under RIDDOR
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995.
Sometimes referred to as RIDDOR 95 or RIDDOR for short, came into force on 1 April
1996. Reporting accidents and ill health at work is a legal requirement. The
information enables ‘the enforcing authorities’ to identify where and how risks arise
and to investigate serious accidents. This then helps us on how to reduce injury, ill
health and accidental loss.
Responsibilities:

Managers: Must telephone the Health and Safety Manager, in the first instance,
when reporting the following:






A fatality
A major injury
An over 7 day injury
A specific notifiable disease
A dangerous occurrence.
Managers: Must contact the Health and Safety Manager to ensure that an “online” report is sent to the Incident Contact Centre. Note: The Incident Contact
Centre is the central point for receiving RIDDOR reports which are then re-directed
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Issue no. 3
Issue Date: July 2013
to the relevant Health and Safety Executive Department or Local Authority
Environmental Health Department.
If for any reason it is not possible to contact the Health and Safety Manager then
Managers should report directly to the RIDDOR Incident Contact Centre
http://www.riddor.gov.uk/ and follow the on-line instructions. On completion, you
must forward a copy of your on-line report (F2508/F2508A etc) to the Health and
Safety Manager.

Managers: Must also complete The Mungo Foundation Incident Report Form
Further information on categories of RIDDOR and reportable details are available
on the
(www.themungofoundation.org.uk/staff/health and safety/H&S Information)
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Issued by: Chief Executive
Issue no. 3
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Incident Occurs
Fatality
Minor Injury
Incident
without
injury /
Near Miss
Inform Line
Manager.
Complete
Incident
Report form.
Conduct
investigation.
Refer to
Incident
Reporting
Policy and
Procedures
Provide First Aid etc where
considered necessary. Inform
Line Manager. Complete
Incident Report form.
Conduct investigation. Refer
to Incident Reporting Policy
and Procedures
NOTE: 1
Major and over 7
day injuries
Provide First Aid,
medical assistance,
A&E etc where
considered
necessary. Inform
Line Manager.
Complete Incident
Report form.
Conduct
investigation. Refer
to Incident
Reporting Policy
and Procedures
Specified Diseases
and Dangerous
Occurrences
Inform Line
Manager.
Complete Incident
Report form.
Conduct
investigation.
Refer to Incident
Reporting Policy
and Procedures
Immediately
contact the
emergency
services for
Medical
Assistance,
the Police,
other
Enforcing
Authorities and
the duty/oncall Manager.
Refer to
Incident
Reporting
Policy and
Procedures.
Physical or Verbal threats,
abuse, assault
Refer to Violence &
Aggression at Work policy
and procedures.
Send Incident Report Form to
Head Office 3 days.
Telephone the Area/Senior
who will seek the
input/guidance from the
Health & Safety Manager for
an “on-line” report to be made
to the Incident Contact
Centre.
Refer to Incident Reporting
Policy and Procedures
Send completed Incident
Report Form to Head Office
within 24 hours
NOTE 2: Any incident
resulting to support / care
practice, illness or the
physical, sensory or
mental impairment of a
service user, medication
practice errors and
challenging behaviour
incidents.
Notify Line Manager and
seek professional
guidance as appropriate
report