REPORTING OF INJURIES, DISEASES AND DANGEROUS
OCCURRENCE POLICY (RIDDOR)
Version
4
Name of responsible (ratifying) committee
Health & Safety Committee
Date ratified
7th May 2014
Document Manager (job title)
Health & Safety Advisor
Date issued
11th June 2014
Review date
10th June 2017 or on change of legislation
Electronic location
Corporate Policies
Related Procedural Documents
Policy for the prevention of Adverse Events and Near
Misses
Policy for the prevention of Adult in-patient falls
Key Words (to aid with searching)
RIDDOR, disease, adverse event, harmful, dangerous
occurrence
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
4
17.05.14
Duties and responsibilities – Director of Workforce to be
notified of all RIDDOR reportable Incidents.
J.Cattle
4
17.05.14
Duties and responsibilities – relevant managers to
ensure Post incident Risk Assessment has been
undertaken
J Cattle
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
CONTENTS
Quick reference guide…………………………………………………………………………………...3
1. Introduction…………………………………………………………………………………….……..4
2. Purpose……………………………………………………………………………………………....4
3. Scope…………………………………………………………………………………………………4
4. Definitions…………………………………………………………………………………………….4
5. Duties and Responsibilities…………………………………………………………………………5
6. Process……………………………………………………………………………………………….6
7. Training requirements……………………………………………………………………..………10
8. References and associated documentation………………………………………………..……10
9. Equality impact statement………………………………………………………………………...10
10. Monitoring Compliance…………………………………………………………….………………11
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
QUICK REFERENCE GUIDE
RIDDOR Reporting Flow Chart
INCIDENT AT WORK
DEATH
The Health and Safety
advisor
should
be
notified within 48 hours.
A RIDDOR form must
be
completed
and
returned at the earliest
opportunity.
YES
NO
YES
‘Specified Injury’
Work related accidents or
Incidents that result in
death should be reported
by the duty hospital
manager. These must be
reported immediately to
the HSE via the incident
contact
centre.
The
Health and Safety advisor
must me notified at the
earliest opportunity.
NO
The Health and Safety
advisor
must
be
informed
of
all
incidents where a staff
member is unable to
undertake their normal
duties or is absent
from work for more
than three days. If this
extends to a seven
day period then the
line manager must
complete a RIDDOR
form and return it to
the Health and Safety
Advisor for submission
to the HSE.
YES
LOSS TIME INCIDENT
NO
RIDDOR reportable
SHARPS INJURY
YES
NO
RIDDOR reportable
DISEASE
YES
NO
The CNS(Falls)
(or the Health and
Safety Advisor in
their absence)
must be informed
of all RIDDOR
reportable patient
Falls within 48hrs.
The ward manager
will be required to
complete and
return the
RIDDOR form
HSE Incident Contact Centre
Health and Safety Advisor
CNS (FALLS)
Duty Manager
These will be
reported by
Occupational
Health
DANGEROUS OCCURENCE
YES
This should be
reported to the
Health
and
Safety Advisor
within 48hrs
NO
YES
RIDDOR reportable
Patient Fall
NO
The incident does not require
reporting under RIDDOR
Mon – Fri 0830-1700
Out of Hours
Ext 3641
Ext 6675
Bleep via Switchboard
0845 3009923
0151 9229235
Direct Dial 02392283641
Bleep 1363
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
1. INTRODUCTION
The reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR)
requires employers to report certain types of injury, some occupational diseases and dangerous
occurrences that ‘arise out of or in connection with work’ to the Health Safety Executive
(HSE) The scope of these regulations cover in brief –

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Accidents which result in death of any person
Accidents which result in an employee or self employed person suffering from a
‘Specified Injury’
Accidents which result in an employee or self employed person being absent from
work or unable to undertake their normal duties for more than seven days
Accidents which result in a person not at work (eg patient, service user, visitor)
suffering and injury and being taken to hospital, or if the accident happens at a
hospital, suffering a major injury which would otherwise have required hospital
treatment
An employee or self employed person suffering from a specified work related
disease
Specified dangerous occurrences, which may not result in a reportable injury,
but have the potential to do significant harm
Generally this covers incidents associated in some way with work activities, equipment or
environment, including how the work is carried out, organized or supervised.
RIDDOR reports enable the HSE or Local Authorities to identify where and how health and
safety risks arise, reveal trends and help target activities. A significant purpose of RIDDOR is to
alert enforcing authorities to events and help them decide whether to investigate serious
incidents.
In order to meet both the legal requirements of Health and Safety at Work and the RIDDOR
Regulations Portsmouth Hospital NHS Trust (the Trust) will ensure that incidents at work are
recorded, investigated and reported. The Trust will aim, through its reporting and monitoring
procedures, to develop a proactive and positive response to incidents at work.
Records of all RIDDOR reportable incidents are maintained for a period of three years
Failure to report a reportable injury, dangerous occurrence, or disease in accordance with the
requirements of RIDDOR, is a criminal offence, and may result in prosecution. Reporting an
incident is not an admission of liability
2. PURPOSE
This document is intended to provide mangers and staff with guidance on RIDDOR reportable
incidents. It contains details of the types of incidents that are RIDDOR reportable and the
methods in which they should be reported.
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
3. SCOPE
The contents and requirements of this policy are applicable to the following groups;
 All paid employees
 Individuals who are not direct employees but who undertake duties on any premises
owned, leased or managed by the Trust. These may include:
- Bank or Agency Staff
- Volunteers
- Contractors and Suppliers working on Trust premises
- Military staff
The trust acknowledges that some staff may be required, as part of their employment, to work
at locations outside of Trust premises. Where this is applicable staff should ensure that they are
familiar with the reporting procedures for that area and that this is followed alongside the
reporting requirements detailed within the Trust’s Adverse Incident and Near Miss Policy.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS – RIDDOR reportable Incidents
Deaths
The death of any person, whether or not at work, must be reported if it results from an
accident arising out of or in connection with work.
Specified Injury
 Fractures (except fingers, thumbs or toes)
 Amputation
 Dislocation of shoulder, hip, knee or spine
 Loss of sight (temporary or permanent)
 Chemical or hot metal burn to the eye
 Penetrating injury to the eye
 Some heat induced illnesses
 Injuries that require hospital admission
 Electrical shock or burns that lead to unconsciousness, requiring resuscitation or
hospital admission
Loss time Accidents to Employees
 An employee being absent from work or unable to undertake their normal duties for
three or more days
 An employee being absent from work or unable to undertake their normal duties for
seven or more days – this is now RIDDOR reportable to the HSE
Physical Violence
Any act of non-consensual violence that results in:
 Death
 A major injury
 An employee being absent from work or unable to undertake their normal duties for
three or more days
Diseases, Infections and ill Health that is believed to be attributable to your work for
example:
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)

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Some skin diseases such as occupational dermatitis
Occupational asthma or respiratory sensitization
Infections such as viral hepatitis, tuberculosis, legionellosis and tetanus
Certain musculoskeletal disorders, such as carpal tunnel syndrome or hand arm
vibration syndrome
Any other infection reliably attributable to work with biological agents, exposure to
blood or body fluids, or any potentially infective material
Other conditions such as occupational cancer
Sharps Injuries
 An employee is injured by a sharp known to be contaminated with a blood borne virus
(BBV) e.g. Hepatitis B, C or HIV. This is reportable as a dangerous occurrence.
 The employee receives a sharps injury and a Blood Borne Virus (BBV) acquired by this
route sero-converts. This is reportable as a disease.
 If the injury itself is so severe that it must be reported
Dangerous Occurrence are specified events, which may not result in a reportable injury, but
have the potential to do significant harm. Examples of dangerous occurrences include:

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

The collapse, overturning or failure of a load- bearing part of lifts or lifting equipment
The accidental release of a biological agent likely to cause severe human illness (a
hazard group 3 or 4 pathogen)
An electrical short circuit or overload causing fire or explosion
Needle stick injuries known to be contaminated with a BBV
Injuries and ill health involving those not at work must be reported if it results from an
accident arising out of or in connection with work being undertaken by others. The following are
examples of incidents that would be deemed as RIDDOR reportable:

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
A patient is scalded by a hot bath
A patient receives a fractured arm when their arm becomes trapped in a bed rail
A visitor to the hospital is struck on the head by a car park barrier and requires hospital
treatment
A patient sustains an injury after sliding through a sling whilst being hoisted
A patient falls from a window and is injured
Reportable Patient Falls
A fall is reportable under RIDDOR when it has arisen ‘out of or in connection with work activity’.
This includes where equipment or the work environment (including how or where work is
carried out, organized or supervised) are included. Examples of patient falls that are RIDDOR
reportable include:



A patient falls out of bed and is injured. An assessment indicated the need for bedrails
but they, or other preventative measures, had not been provided.
A patient falls and is injured, there is a previous history of fall incidents, however
reasonably practicable measures to reduce the risks have not been put in place, for
example- an adequate falls assessment had not been undertaken
The falls is attributable to an environmental condition such as – wet floor, trailing leads
or loose damaged floor surfacing.
It should be noted that the examples given within this policy are not exhaustive. If there is any
uncertainty as to whether or not an incident is RIDDOR reportable the Health and Safety
Advisor should be contacted for advice.
Further information on RIDDOR reportable incidents can be found on the Health and Safety
web pages
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
5. DUTIES AND RESPONSIBILITIES
Director of Workforce and Human Resources has been delegated the responsibility for the
operational implementation of all Health and Safety related policies by the Chief Executive.
On notification of a RIDDOR reportable incident they will, where required, chair a review of the
incident to ensure that all appropriate actions have been undertaken and that lessons learnt are
shared.
Executive Directors and Clinical Directors are responsible for ensuring that the
requirements of this policy are effectively implemented in their areas of responsibility.
Clinical Service Centre Managers/Operational Managers and Line Managers are
responsible for ensuring that:
 Accidents and Incidents are, in the first instance, appropriately recorded in accordance
with the Trust’s Adverse Incident Reporting (AIR) system
 Appropriate systems are in place to investigate incidents that occur within their work
environment.
 The Health and Safety Advisor is informed of all staff incidents that result in an
employee being absent from or unable to undertake their normal duties for three or
more days.
 That the Health and Safety Advisor is informed of all RIDDOR reportable incidents
within a timely manner.
 All appropriate actions have been taken to prevent reoccurrence of such incidents.
 Post incident Risk Assessment has been undertaken
Duty Hospital Manager will, in the event of a fatality or potentially life threatening serious
injury:
 Be responsible the initial management of the incident scene.
 Ensure that where there is police attendance that they are fully supported
 Ensure that the On Call Director is notified
 Liaise with the police in respect of notification to the HSE
 Ensure that the Health and Safety Advisor is notified at the earliest opportunity
In most circumstances the police will contact and discuss the incident with the HSE, the
local authority or other enforcing authority however this responsibility may fall to the duty
manager to undertake.
Occupational Health is responsible for:
 Reporting to the HSE any case of Occupational Disease or Sharps Injury as detailed in
section 6.
 Ensuring that, for the purpose of reporting and collating, numbers of these incidents are
provided to the Health and Safety Advisor as requested.
 Undertaking any appropriate investigations relating to RIDDOR reportable sharps
injuries and Occupational Disease.
 Ensuring that records of such incidents are held for a minimum of five years.
Due to the sensitive nature of reporting diseases or infections caused by BBV’s, the enforcing
authority does not require the injured person to be named on the reporting form. However, if the
reporting
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
Health and Safety Advisor will ensure that:
 A record of all RIDDOR reportable incidents is maintained
 Where notified, a record of all loss time (over three days) work related incidents is
maintained
 With the exception of sharps injuries and occupational disease (as these are reported
by Occupational Health) will ensure that the HSE are notified of all RIDDOR reportable
incidents within the regulatory time frame.
 Department mangers are, where required, given the necessary support and guidance to
investigate RIDDOR reportable incidents.
 The Trust is kept informed of RIDDOR reportable and loss time incidents by means of
regular reports to the Health and Safety committee, Quality and Governance and The
Trust Board.
 The director of Workforce and Human Resources is notified of all RIDDOR reportable
Incidents
The Clinical Nurse Specialist for Falls and Bone Health - The CNS (Falls) will:
 Assist managers in the identification of RIDDOR reportable patient fall incidents
 Ensure that RIDDOR reportable fall incidents are investigated via the appropriate route
 Ensure that the RIDDOR reporting form is completed and sent to the Health and Safety
Advisor for to action and collate.
All Staff are required to:
 Observe safe working practices ensuring that they do not willfully endanger themselves
or other whilst on duty.
 Report incidents appropriately in accordance with the trust’s AIR policy
 Report potential Hazards to the appropriate person
 Cooperate with their managers
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
6. PROCESS
INCIDENT AT WORK
DEATH
The Health and Safety
advisor must be notified
within 48 hours. The
person reporting will be
forwarded a RIDDOR
form to complete and
return
YES
NO
YES
Specified Injury
Work related accidents or
Incidents that result in
death should be reported
by the duty hospital
manager. These must be
reported immediately to
the HSE via the incident
contact
centre.
The
Health and Safety advisor
must me notified at the
earliest opportunity.
NO
The Health and Safety
advisor
must
be
informed
of
all
incidents where a staff
member is unable to
undertake their normal
duties or is absent
from work for more
than three days. If this
extends to a seven
day period then the
line manager must
complete a RIDDOR
form and return it to
the Health and Safety
Advisor for submission
to the HSE.
YES
LOSS TIME INCIDENT
NO
RIDDOR reportable
SHARPS INJURY
YES
NO
RIDDOR reportable
DISEASE
YES
NO
The CNS(Falls)
(or the Health and
Safety Advisor in
their absence)
must be informed
of all RIDDOR
reportable patient
Falls within 48hrs.
The ward manager
will be required to
complete and
return the
RIDDOR form
These will be
reported by
Occupational
Health
DANGEROUS OCCURENCE
YES
This should be
reported to the
Health
and
Safety Advisor
within 48hrs
NO
YES
RIDDOR reportable
Patient Fall
NO
The incident does not require
reporting under RIDDOR
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
The director of Workforce and Human resources will be notified by the Health and Safety
Advisor of all RIDDOR reportable Incidents.
HSE Incident Contact Centre
Health and Safety Advisor
CNS (FALLS)
Duty Manager
Mon – Fri 0830-1700
Out of Hours
Ext 3641
Ext 6675
Bleep via Switchboard
0845 3009923
0151 9229235
Direct Dial 02392283641
Bleep 1363
7. TRAINING REQUIREMENTS
Although there is no specific training requirement for the implementation of this policy
Managers should ensure that they, and the staff that they manage are familiar with the
requirements of this policy and the processes for Incident reporting within the trust.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
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The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Reporting Injuries, Diseases and Dangerous Occurrences in health and social care:
Guidance for Employers
Policy for the Management of Adverse events and Near misses
Policy for the Prevention and Management of Adult In-Patients at Risk of Falling or who
have already Fallen
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
10. REFERENCES AND ASSOCIATED DOCUMENTATION
Procedural documents must be evidence-based and referenced, wherever possible.
References could include any associated national policies, standards, guidelines, Acts of
Parliaments.
References and associated documents must be checked when reviewing an existing
procedural document, to ensure they are still current and relevant.
The following referencing format must be used:
An Organisation-Wide Policy for the Development and Management of Procedural Documents:
NHSLA, May 2007. www.nhsla.com/Publications/
11. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy
Documentation
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)
12. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
Minimum requirement
to be monitored
Reported Hazards
Lead
H&S Advisor
Tool
Frequency of
Report of
Compliance
DATIX System
Policy audit report to:
Quarterly
6 Monthly
Annual
Number RIDDOR reports
submitted to HSE
H&S Advisor
H&S
record
Reporting arrangements
maintained

H&S Committee,

G&Q Committee

Trust Board
Policy audit report to:
Reported to
director of
WF monthly
each H&S
committee
And
on
relevant
governance
reports

Lead(s) for acting on
Recommendations
H&S Advisor
H&S Advisor
H&S Committee,
G&Q Committee

Trust Board
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Development and management of Procedural Documents: Version 4 Issue Date: 11.06.2014
Review date 10.06.2017 (unless requirements change)