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Critical and major incident plan

Contents

  1. Aim and objectives
  2. Scope
  3. Definition of incidents
  4. Training and exercise
  5. Links to other plans
  6. Trust command and control structure
  7. Plan activation
  8. Incident stand down
  9. Communications
  10. Administrative support to gold command
  11. Engagement with external partners
  12. Critical or major incident recovery
  13. Recovery cell
  14. Tactical operational recovery cell draft terms of reference
  15. Debriefing
  16. Support for staff
  17. Equality impact assessment screening
  18. Appendices

To declare a critical or major incident and call a gold command meeting, go to appendix E.

1 Aim and objectives

The aim of the plan is to ensure a timely and appropriate response and recovery to a critical or major Incident and will ensure effective partnership working with emergency responders and other partner agencies as appropriate.

In the event of a critical or major incident the trust will aim to:

  • protect Life
  • protect the health and safety of people
  • give consideration to vulnerable members of the community
  • warn and inform the public
  • support staff, before, during and after any response to a major incident
  • working with and co-operate with partner agencies
  • prevent escalation
  • restore back to business as usual as soon as possible

2 Scope

The plan sets out the corporate response arrangements required internally for the management of disruptive incidents.  It covers the response from Rotherham, Doncaster and South Humber NHS Foundation Trust and its associated footprint. It is not aimed to be a multi-agency document and should be read in conjunction with other trust and external plans as appropriate.

The plan falls under the scope of the overall trust emergency preparedness, resilience and response (EPRR) policy.

3 Definition of incidents

The NHS England emergency preparedness, resilience and response framework (EPRR) sets out the definitions of each type of incident:

For the NHS, incidents are classed as one of the following:

  • business continuity incident
  • critical incident
  • major incident

Each will impact upon service delivery, may undermine public confidence and require contingency plans to be implemented.

The trust should be confident of the severity of any incident that may warrant a major Incident declaration, particularly where this may be due to internal capacity pressures, if a critical Incident has not been raised previously through the appropriate local escalation procedure (see appendix C to E). Refer also to section 10 of this plan.

3.1 Business continuity incident

A business continuity incident is an event or occurrence that disrupts, or might disrupt, the trust’s normal service delivery, below acceptable predefined levels, where special arrangements are required to be implemented until services can return to an acceptable level. (This could be a surge in demand requiring resources to be temporarily redeployed or a localised loss of telephony or IT.)

3.2 Critical incident

A critical incident is any localised incident where the level of disruption results in the trust temporarily or permanently losing its ability to deliver critical services; patients may have been harmed or the environment is not safe requiring special measures and support from other agencies, to restore normal operating functions (this could be a response to a widespread IT outage affecting access to patient data).

3.3 Major incident

A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented.

For the NHS this will include any event defined as an emergency as below.

Under section 1 of the Civil Contingencies Act (CCA) 2004 an “emergency” means:

  • an event or situation which threatens serious damage to human welfare in a place in the United Kingdom
  • an event or situation which threatens serious damage to the environment of a place in the United Kingdom
  • war, or terrorism, which threatens serious damage to the security of the United Kingdom”

3.4 NHSE(I) incident levels

The NHS England EPRR framework also includes information about incident levels to be used by all NHS organisations when referring to incidents (for example, at its peak, the COVID 19 pandemic was a level 4 incident).

  • Level 1, an incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Coordinating organisation led by affected organisation with support from their ICB (place)
  • Level 2 an incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. Coordinating organisation led by the ICB with support from the regional EPRR team.
  • Level 3, an incident that requires the response of a number of health organisations across geographical areas within a NHS England region. Coordinating organisation NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Led by NHS England North East and Yorkshire regional team.
  • Level 4, an incident that requires NHS England national command and control to support the NHS response. Coordinating organisation NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Led by NHS England national team.

4 Training and exercise

This plan will be tested in accordance with the schedule set out in the annual EPRR exercise plan. This plan will be tested every three years unless the plan is activated during an incident.  Where this occurs, a full debrief and any necessary amendments will be made to the plan and an exercise will not be necessary for that year.

A training and exercise record can be found at appendix T.

5 Links to other plans

This plan should be used in parallel with emergency type-specific plans held by the trust. Up to date versions of all trust plans can be found on the intranet.

Examples of trust plans available are:

Several multi agency plans exist that may impact on trust response and should be consulted as appropriate. These are all contained in the on-call folder. Updated versions may be obtained from the relevant local resilience forum (LRF).

  • Yorkshire and The Humber mass casualty framework for health
  • South Yorkshire LRF multi agency flood plan
  • Humber LRF multi agency flood plan
  • Humber LRF East Coast tidal inundation plan
  • South Yorkshire LRF East Coast tidal inundation protocol

6 Trust command and control structure

6.1 The role of a strategic and tactical leader

Within the trust strategic leaders are those members of staff on the on call director (gold) rota.

The role of a strategic leader in a critical or major incident is to ensure that there is a planned and considered implementation of arrangements to mitigate the impact of the incident through ongoing collaboration, coordination and communication, both within their own organisation and with partner organisations.

Strategic leaders must also ensure that appropriate resources to support the response are made available from within their own organisation.

Depending upon the nature of a critical or major incident, strategic Leaders would be expected to call and chair a trust gold command meeting.

The joint decision model (JDM) has been adopted by the trust and is used to support decision making at both strategic (gold) and tactical (silver) levels to achieve effective coordination and better outcomes in response to incidents.

The trust tactical leaders are those members of staff on the silver on call rota. In a critical or major Incident they may be identified as silver commanders and chair silver command meetings.

The role of a tactical leader in the critical or major incident is to provide the link between the strategic decision making at gold command the operational delivery of service at bronze levels.

Silver commanders may request gold to consider requests to adjust, adapt or close services.

6.2 Trust gold command (strategic)

This group comprises of strategic level representatives likely to be integral to the strategic response to the incident. Others may be added at the discretion of the gold command chair. In normal office hours the position of chair or gold commander would normally be held by the chief operating officer. Out of hours the position of chair or gold commander would be assumed by the director on call until such time at which it may be changed.

  • The gold command provides strategic leadership.
  • It should try to avoid tactical or operational level decision making where possible by delegating where appropriate to silver command.
  • It is the most senior decision making within the trust for matters concerning response to an incident.
  • It should include decision makers of appropriate seniority and scope. This may include some or all of the Executive Management team (EMT). EMT should not duplicate matters discussed at gold command.
  • Depending on the nature of the incident gold command may include the following staff (this list is not exhaustive):
    • chief executive
    • chief operating officer
    • director health informatics
    • executive medical director
    • head of estates and facilities
    • Head of communications
    • director of strategy
    • executive director of nursing and allied health professionals and deputy chief executive
    • executive director of finance and performance
    • director of corporate assurance or board secretary
    • executive director for people and organisational development
    • clinical lead(s) as appropriate
    • EPRR manager
    • loggist (required at all gold command meetings, either in person or remotely via MS Teams

In a lengthy incident deputies should be identified for all gold command roles.

Also, in a cyber or data security incident it is a legal requirement for the data protection officer to be informed and involved in all cyber, data security, or information incidents, in alignment with the trust cyber and data security incident plan.

Depending on the scale and duration of an incident gold command will require a degree of administrative support. For example, a response to a pandemic would require significant administrative support to ensure that agendas, papers and correspondence is organised and stored appropriately. Administrative support differs to the role of incident loggist.

Action cards can be found in the appendix for the following gold command roles:

  • accountable emergency officer or gold command chair
  • incident co-ordinator
  • incident loggist(s)
  • administrative support
  • head of communications

A full terms of reference and draft gold command agenda are stored in the appendix.

6.3 Gold command, specialist cells

Depending on the nature of the incident gold command should consider the establishment of specialist subject cells to support it in meeting its agreed objectives. This may include the management and interpretation of incoming guidance. Specialist cells allow the trust to work proactively to respond to challenges in specific areas. Examples of specialist cells are as follows:

  • infection prevention and control
  • workforce
  • ethics
  • vaccination
  • health informatics
  • tactical and operational recovery working group
  • personal protective equipment (PPE)

Cells should present their updates as and when required by gold command. A template for specialist cell updates is contained in the appendices.

6.4 Trust silver command (tactical)

These are tactical level decision makers and in most cases comprise of members of the care group triumvirate of each care group and support staff. For example the care group director for children’s services would also be children’s services silver commander. Care group nurse directors may deputise for care group directors as silver commanders. Any staff member on the silver on call rota may act as a silver commander if they are familiar with the care group. An action card for silver commanders is included in the appendix along with a draft silver command terms of reference and draft agenda.

Silver commands take direction from gold command and would coordinate response to the incident for each care group and liaise in turn with bronze commanders (team managers and modern matrons). Silver is the busiest tier of command and control during response to an incident and should be adequately resourced. Silver commands also require an incident loggist.

Silver commands can also request gold command should they wish to make changes or adjustments to services. A template for silver requests to gold command is included in the appendix.

Care group staff may be required to represent the trust at external meetings or teleconferences and administrative support would be needed for larger scale incidents.

Within each silver command the care group medical director should act as liaison between management and medical delivery to ensure coordination between medical and non-medical staff.

Within corporate services the directors with responsibility for them that attend gold command should ensure that information and instructions are cascaded appropriately.

6.5 Trust bronze commands (operational)

These are operational level decision makers and will comprise of individual service managers. For example the service manager of the Doncaster single point of access team would be a bronze commander. They will also be in liaison with medical staff at bronze level to ensure coordination of action.

Bronze commands take direction from silver command. Non-clinical services should also have bronze commanders at team manager level. The silver commander of each non-clinical service will identify the bronze commanders within their service. An action card for bronze commanders can be found in the appendix.

6.5.1 Strategic

Trust gold command:

  • sets strategic direction
  • coordinates responders
  • prioritises resources

6.5.2 Tactical

Trust silver command(s):

  • interprets strategic direction
  • develops tactical plan
  • coordinates activities and assets

6.5.3 Operational

Trust bronze commands:

  • executes tactical plan
  • commands single-team or service response
  • coordinates actions

7 Plan activation

A critical or major incident may be triggered in a number of ways.   Internally this may be triggered by an incident such as a serious fire or security incident.

If an incident is occurring external to the trust notification may come from a partner agency such as the ambulance service or local authority. This may be received via telephone or email. In some instances, such alerts may also come directly from NHS England at regional or national level.

Severe weather incidents would see alerts and warnings come from the met office or environment agency. The trust severe weather plan give details.

In all cases partner agencies have been given the trust’s out of hours contact details so they may inform on call directors (gold).

This plan will be activated upon receipt of information which indicates that a critical or major Incident has occurred that affects the trust as per the definitions above. In order to gather sufficient information to inform a decision whether to activate this plan it is recommended that the initial response aide memoire be completed along with a situation, background, assessment, recommendation (SBAR) form. Both documents are included in the appendix.

Cascade arrangements showing the procedure for declaring a critical or major incident can be found in the appendix.

  • Microsoft Teams Conferencing. Gold command should primarily be convened as an MS Teams meeting. Participants will be contacted via email with a link to the MS Teams at the time gold command will be held. Draft agendas and Terms of Reference are contained in Gold and silver on call folders in “L:\Corporate\Trust OnCall Rotas\Gold” and silver on call folder.
  • Face-to-face gold command meetings can be held at our incident coordination centre (ICC). Boardroom 2 of Woodfield House, Tickhill Road Hospital, Doncaster, DN4 8QN. This is a secure location available 24 hours a day, 7 days a week, outside of likely flood areas with easy access from the motorway network, adequate car parking, IT and communication connections, and backup generator power. See the appendix for the action card for setting up the ICC.
  • Telephone conferencing. Should MS Teams be unavailable details of how to hold a telephone conference are stored in the emergency planning cupboard in the ICC room and “L:\Corporate\Trust OnCall Rotas\Gold” and silver on call folder documents.

8 Incident stand down

Gold command is responsible for the decision of when to stand down a critical or major Incident response. When doing so it will ensure communications are issued to all staff and external partners.

9 Communications

In a critical or major incident, clear and coordinated communications with staff, the public and partner organisations are essential. Trust communications should, be consistent with those coming from partners nationally and locally. The trust emergency preparedness, resilience and response communication policy explains the trust’s duties to warn and inform staff, public and partners.

In the event of a loss of internet connection affecting MS Teams staff are advised to use mobile or landline communications as an alternative or email where possible and appropriate. Arrangements for using telephone conferencing are available in gold on call folders. Up to date gold on call folders can be found in “L:\Corporate\Trust OnCall Rotas” and gold and silver on call staff should maintain an up-to-date hard copy.

Should all landline, mobile and internet based communications be lost, the accountable emergency officer or deputy will consider moving to an “in person” incident control centre (ICC). Details of how to set up the ICC at Woodfield House are contained in the appendix. In the event of main switchboard loss switchboard staff would follow procedures in their BCP.  Directors should refer to the emergency preparedness, resilience and response communication policy for options for how to communicate with staff, patients and the public.

10 Administrative support to gold command

10.1 Record keeping mechanisms and responsibilities

During a critical or major Incident it is imperative that accurate records are kept of decisions and actions. It is also vital to accurately record the rationale behind those decisions.

The reason for this level of detailed record keeping is that each critical or major incident and the trust’s response may be subject to a public inquiry or audit. Should there be any adverse effects created as a result of actions or decisions taken by the trust in response to a critical or major incident, each of those decisions needs to be justified and this can only happen within the context of detailed and accurate record keeping. This will be undertaken by:

  • trained incident loggists at gold and silver commands. Loggists must have undertaken the approved loggist training provided by NHSE(I) or UKHSA
  • in the absence of a trained loggist or other suitable staff members directors must keep their own accurate, contemporaneous where possible, record of events and actions

The names and contact numbers of trained loggists are contained in the director on-call packs.

Gold and silver commanders will ensure that loggists work in suitable shifts to ensure they can access adequate rest periods. Ideally there should be a team of no less than 5 loggists supporting gold or silver commands to provide adequate cover. A rota should be provided to ensure all meetings are covered.

The overall responsibility for record keeping rests with the accountable emergency officer or gold commander.

Specially trained loggists identified within the trust will, where required, relinquish their usual duties in the event of a critical or major incident and work remotely or in person as required. See the appendix for action cards outlining responsibilities.

The accountable emergency officer or gold commander will ensure that all notes, logbooks and any other documentation produced during the incident are collated, filed and kept securely for a minimum period of ten years. Any disposal of records should be done in consultation with the Information Governance team.

For these purposes ‘documents’ or ‘records’ means electronic, paper, photographs, audio and video tapes, and information held on mobile devices and computers. It also includes electronic mail, documents and images.

10.2 Situation reporting (SITREPS)

During a critical or major incident it will be necessary for the trust gold command to gather information from individual care groups on their response to the incident. This reporting will be initiated by gold command and cascaded to silver commands who will liaise with bronze commands within their care groups to gather the necessary information.

The situation report template for care groups is included in the appendices.

Should situation reporting be required gold command will need to ensure the following:

  • a clear timetable for submission that allows a reasonable timescale for sit reps to be compiled and collected
  • clear instructions as to where silver commands should send completed sit reps, for example, emergencyplanning@nhs.net or a new generic email address to deal with specific incident related matters
  • awareness of demands for information from external organisations such as ICBs, local authorities and NHS England and ensure the timetable for collecting information internally fits in with local and regional reporting arrangements
  • all completed sit reps are saved in a specific incident folder on L Drive that may be accessed only by appropriate staff. Each sit rep should be stored individually and dated as follows day, month, year, for example, 01022021

10.3 Situation reporting requests from external partners

A critical or major incident is likely to result in information requests from partners such as NHSE(I), ICBs and ICSs. Sit reps from NHSE may require submission via online platforms such as the NHSI strategic data collection service (SDCS).  Sufficient staff will need access to this system and training to ensure the trust is able to meet submission deadlines.

Gold command should establish as soon as possible whether data required in sit reps can be taken directly from SystmOne to minimise time and resources spent on gathering information.

10.4 Preparation of agendas and papers

Sufficient resource should be provided to support each gold or silver command meeting to ensure agendas and papers are organized in good time. Ideally a small team of administrative staff will share this function to provide resilience. This team should ensure that papers are accessible to appropriate staff via the shared drive.

10.5 Guidance log

Any long running incident is likely to attract input from external partners and central government. This may result in the issue of guidance covering all aspects of incident response. The trust may need to evidence its response to such guidance if a public inquiry is held. It will be necessary to keep a log of guidance received and how it is dealt with to ensure that adherence to guidance can be demonstrated. An example of the guidance log can be found in the appendix.

11 Engagement with external partners

The trust is required to consult with the appropriate integrated care board (ICB) before declaring a major incident.

A critical or major incident is likely to involve external partners and gold command should ensure that the trust is represented at all appropriate external meetings. For cross border multi agency incidents, for example, pandemics or widespread severe weather there may be ICB level meetings that require attendance. There may also be meetings at place level, for example, Doncaster, Rotherham and North Lincolnshire. Gold command will decide who will attend such meetings and how feedback from them will be provided.

11.1 Mass casualty incidents

NHS England defines a mass casualty incident for the health services as an incident (or series of incidents) causing casualties on a scale that is beyond the normal resources of the emergency and healthcare services ability to manage. A mass casualty incident is likely to involve hundreds or thousands of casualties with a range of injuries, the response to which will be beyond the capacity of normal major incident procedures to cope and therefore require further measures to appropriately deal with the casualty numbers.

Declaring a mass casualty incident will be a judgement based on a combination of factors, including the number and types of casualties; but also, the ability of local services to become overwhelmed. This declaration will then initiate the NHS England Yorkshire and the Humber command, control, co-ordination and communications arrangements, which will as a process step, ensure contact is made with the North East and Yorkshire Region EPRR team or on-call officer.

ICBs may be asked to support NHS England by providing representation at NHS England’s incident coordination centre (ICC) working alongside the incident manager and reporting into the multi-agency tactical coordinating group (TCG). ICBs may activate local health partner tactical coordinating groups at place level.

Trust response to a mass casualty incident would require activation of multi-agency surge plans at local levels. This will assist with patient flow across the system that will help acute trusts deal with an influx of casualties and help prevent admission to acute trusts from non-incident related sources where possible.

If such an incident occurs the AEO will work with the EPRR manager and on-call staff to make trust resources available to assist with response. This would ensure suitable attendance at TCGs and other coordination meetings where required. Internally the AEO would coordinate trust response in the following areas:

  • patient flow within physical health services to assist with discharge from acute services
  • mental health services, specifically in ensuring assistance is provided appropriately in the short, medium and long term as required
  • estates services, if trust estate may be brought into use to assist partner agencies

12 Critical or major incident recovery

Recovery is distinct from, but will usually overlap with, the response to the incident, and is an integral part of the emergency management process.

Recovery is a coordinated process of supporting affected patients, staff and stakeholders in the restoration of services and possibly the reconstruction of the physical infrastructure.

The manner in which recovery processes are undertaken is critical to their success. In many scenarios, the response phase to an emergency can be relatively short in contrast to the recovery phase. Recovery usually takes years rather than months to complete as it seeks to address the enduring human, physical, environmental, and economic consequences of emergencies.

13 Recovery cell

Gold command may wish to consider if the size and impact of the incident merits the establishment of a full recovery cell or whether recovery can be managed within “business as usual” protocols.

The recovery cell may be formed upon the instruction of trust gold command.  It may act as a specialist subject cell during the response to the incident and would be made up of senior staff, representing care groups, corporate and support services as required.

This group will oversee the recovery to ensure it is co-ordinated and report to gold command during the response to the incident and Executive Management team (EMT) after incident stand down.

14 Tactical operational recovery cell draft terms of reference

The aims and objectives of the tactical operational recovery cell fall under three pillars:

14.1 Programme pillar 1

Recovering and resetting services to meet the needs of our patients and safely manage any patient backlogs and to meet the requirements of our commissioners and system partners to ensure a safe, robust and responsive health and social care system.

14.1.1 Delegated work areas

Use data, service intelligence to develop, or deliver a prioritised operational recovery and reset plan for services, taking account of individual care group (thick line) and collective standardised (thin line) requirements.

  • To address waiting lists.
  • To address stepping up of suspended services.

14.2 Programme pillar 2

Transforming services by sustaining and amplifying positive change implemented as part of our critical or major Incident response; and working with our system partners to encourage them to do the same.

14.1.2 Delegated work areas

Use data, feedback, or service intelligence to inform transformational changes across all clinical services, including but not exclusive to digital transformation in clinical care delivery and estates rationalisation.

  • This may be nationally, regionally or locally driven change.
  • For internal transformational changes enacted outside of operational services, it is proposed that tactical (silver) is the route of initial request to ensure understanding and oversight.

Reliant on benchmarking report to assess contact type.

14.3 Programme pillar 3

Preparing ahead for the medium and long term impacts of the critical or major Incident on our patients numbers, acuity and complexity and to future proof our services.

14.1.3 Delegated work areas

Use data or service intelligence to understand recurrent or sustained changes in service demand or activity profiles and take steps to ensure stability in service delivery.

  • Reliant on RRT dashboard activity or demand analytics.
  • Reliant upon capacity and demand modelling.
  • Reliant upon emergent forecast planning.
  • Address any areas of service creep from contracted specification.

14.4 Attendees

  • Chief operating officer (chair).
  • Deputy chief operating officer (deputy chair).
  • Care groups representatives (minimum of one for each care group)
  • CSI leads.
  • Data quality and process improvement lead.
  • Director of strategy (or deputy).
  • Head of performance, contracting and CQUIN (or deputy).
  • Head of HR and workforce.
  • Change and Transformation team representative.
  • Deputy medical director.
  • Deputy chief nurse.

If unable to attend, a suitable representative must be nominated to attend in member’s place.

Attendees will have a responsibility to represent and consider information in order for decisions to be made, where the identified member is unable to attend, the identified representative must be able to make decisions in their absence.

If members cannot attend, it is expected that they will have carried out any allocated actions from previous meetings and circulated a response in their absence or provided to the identified representative to feedback on their behalf.

If required to attend, by invitation:

  • clinical leads
  • service management leads
  • deputy care group directors corporate heads of service
  • professional leads
  • director of psychological therapies
  • chief AHP
  • head of estates and facilities
  • head of HR or workforce
  • health informatics representative
  • Communications team representative
  • Finance team representative

14.5 Frequency

Bi-weekly, 1 to 1.5 hours.

14.6 Quoracy

5 members, inclusive of chair or deputy chair and at least 1 representative from each care group.

14.7 Support arrangements

  • Format, MS Teams.
  • Agenda, standard agenda set by chair, with member escalation for any specific matters for discussion.
  • Papers, to be available on the shared drive at least 3 days in advance of the meeting.
  • Action notes, to be taken for every meeting.
  • Decision log, to be maintained for all decisions.

14.8 Governance rules and behaviours

  • Collective responsibility or decision making in line with individual delegated authorities, arbitrated by the chair.
  • All members are expected to attend, absenteeism is an exception.
  • Meetings will start and end on time.
  • Authority to cancel meeting: chair.

14.9 Standing agenda items

  • Welcome and apologies.
  • Declarations of interest.
  • Action log review.
  • Core business discussions.

To include discussions of current position, next steps, risks and enablers:

  • matters for escalation, decision, or feedback
  • any other business

Note, where dedicated task and finish groups are in situ, discussions at Tactical will not repeat, but will instead focus on discussions, action, or decisions required in the interim period between task and finish meetings to maintain progress and momentum.

14.10 Reporting arrangements

From tactical operational recovery cell:

  • during critical or major incident response the group will report to trust gold command and provide specialist subject cell reports as requested
  • post critical or major incident stand down updates will flow through established governance groups such as EMT by exception, as required
  • updates or feedback relevant to care groups through the identified governance structure within each care group, facilitated by the care group representative in attendance

To tactical operational recovery cell:

  • updates and feedback relevant to delegated work areas

14.11 Monitoring

Terms of reference will be reviewed after 1 month and then every 3 months thereafter.

15 Debriefing

Debriefing following an incident will follow the trust standardised template for reflection and action unless guidance received from NHSE requires a different approach.

A debrief template form is available at appendix S. Debriefs from business continuity, critical and major incidents will be shared with the business continuity and EPRR manager and noted at EPRR group and further action taken where necessary to ensure lessons learned are disseminated.

16 Support for staff

A critical or major incident could put staff under considerable pressure. Guidance for the provision of psychosocial support to staff can be found here: healthy workplaces policy.

Health and Wellbeing support is also provided to all staff. Support available includes an employee assistance programme, 24 hours a day, 7 days a week, confidential support line providing practical support by trained professionals on a range of issues such as bereavement, debt, anxiety, gambling, addiction, relationship issues and more.

Other areas covered by health and wellbeing support can be found on the trust health and wellbeing support intranet (staff access only) (opens in new window).

A post incident psychological support service will form part of recovery work providing training sessions for managers involved in traumatic events (including the provision of debriefs) and also training for wellbeing champions and other champions who may also be supporting after an incident.

17 Equality impact assessment screening

To access the equality impact assessment for this policy, please see the overarching equality impact assessment.

18 Appendices

18.1 Appendix A Incident aide memoire

18.1.1 Who is calling?

  • Name?
  • Agency?
  • Position?
  • Contact number and email?
  • What time?

18.1.2 What has happened?

  • Location and postcode?
  • Building name?

18.1.3 Any Casualties?

  • Number and type?
  • Patient(s) and NHS number(s)?
  • Staff?
  • Public?

18.1.4 Any hazards present?

  • Live cables?
  • Rising floods?
  • Risk of infection?

18.1.5 Are emergency services required?

  • Have emergency services been called or on scene?
  • Who is the emergency services contact?

18.1.6 Do I need to inform others?

  • Inform silver or gold colleagues?
  • On call staff?
  • Do I need to inform partners?

18.1.7 Check resources in on call folder in L Drive.

  • Have business continuity plans been activated?
  • Is this a critical or major Incident?

18.1.8 Next steps

  • Agree timetable for future calls.
  • Agree who will join the calls.
  • If escalating this incident fill out SBAR form.

18.1.9 Start a log

  • Include all actions or decisions and rationale.

18.1.10 Joint decision model

Working together saving lives, reducing harm.

  1. Gather information and intelligence.
  2. Assess risks and develop a working strategy.
  3. Consider powers, policies and procedures.
  4. Identify options and contingencies.
  5. Take action and review what happened.

18.2 Appendix B SBAR report

18.3 Appendix C Trust normal hours cascade system

  1. Manager (bronze) becomes aware of potential emergency situation and contacts care group director (silver). Completes Incident aide memoire and SBAR report, appendix A and B.
  2. Care group director or silver (CGD) informed of incident. If unable to resolve seeks advice from director (gold). Sends SBAR report.
  3. Director informed by silver of incident. If unable to resolve will contact AEO (chief operating officer), EPM and other staff as appropriate:
    • outside agency such as NHS England or local authority may contact AEO or EPM directly to inform them of a major incident
  4. AEO or deputy using SBAR given will decide action, declare critical incident or major incident standby or activate major incident plan. And inform all relevant staff and partners (including ICB).
  5. Declare critical or major incident, see action card in appendix E.
  6. Activate major incident plan.

18.4 Appendix D Trust out of hours on-call cascade system

  1. On call manager (bronze) informed of incident and contacts care group director (On call silver). Completes incident aide memoire and SBAR report, appendix A and B.
  2. Outside agency such as NHS England or local authority may contact the trust directly to inform them of a major Incident.  This may be via switchboard to on-call staff.
  3. On-call silver informed of incident. If unable to resolve contacts director on-call (gold) and sends SBAR report.
  4. Director on-call informed by silver on-call incident. If unable to resolve will contact other staff and directors as appropriate.
  5. Director will decide whether to move to critical incident or major incident standby or activate and inform all appropriate staff and partners (including ICB).
  6. Declare critical or major incident, see action card in appendix E.
  7. Activate major incident plan.

18.5 Appendix E Declaring a critical or major incident

18.6 Appendix F Incident coordinator role card

18.7 Appendix G Loggist role card

18.8 Appendix H Action card notifying the ICB

For senior member of staff notifying ICB of a critical or major Incident out of hours.

18.8.1 Accountable emergency officer

NHSE classifies Incidents as follows. In the first instance on call gold should contact the relevant ICB on their on-call number:

  • South Yorkshire SPOC: 01709 820 000
  • Humber and North Yorkshire SPOC: 0300 002 0005
  • Level 1, an incident that can be responded to and managed by a local health provider organisation within their respective business as usual capabilities and business continuity plans in liaison with local commissioners. Coordinating organisation led by affected organisation with support from their ICB (place)
  • Level 2, an incident that requires the response of a number of health providers within a defined health economy and will require NHS coordination by the local commissioner(s) in liaison with the NHS England local office. Coordinating organisation led by the ICB with support from the regional EPRR team.
  • Level 3, an incident that requires the response of a number of health organisations across geographical areas within a NHS England region. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Coordinating organisation led by NHS England North East and Yorkshire regional team
  • Level 4, an incident that requires NHS England national command and control to support the NHS response. NHS England to coordinate the NHS response in collaboration with local commissioners at the tactical level. Coordinating organisation led by NHS England national team

There are a number of EPRR specific risks where provider organisations will escalate to the NHSE regional EPRR SME on call, this includes but not limited to:

  • level 3 incidents
  • incidents requiring regional support or advice or where there is significant reputational or media interest
  • counter terrorism or security incidents
  • HAZMAT or CBRN incidents (including access to counter measures)
  • military aid to the civil authorities (MACA)
  • deficit of interoperable capabilities (for example, HART or SORT capability)
  • if an SCG or TCG is called to agree what support is required

If in doubt, colleagues should contact the NHSE EPRR SME for advice 01143 240458 (option 5).

18.9 Appendix I Silver commander role card

18.10 Appendix J Bronze commander role card

18.11 Appendix K Care group daily sit rep template

18.12 Appendix L Draft terms of reference for trust gold command

18.12.1 Draft aims for gold command

  • To provide a strategic command and control for the trust across all areas of business in relation to the incident.
  • To minimise disruption to trust services caused by the incident.
  • To ensure a continued safe and caring environment for patients and staff.
  • To ensure coordination of response with external agencies.

18.12.2 Draft objectives for gold command

1. To consider the impact on service delivery and ensure close liaison with silver commanders (care group directors or associate nurse directors).

2. To ensure communications with staff, patients, partners and public are accurate, timely and consistent.

3.To ensure situation reporting is conducted in a timely manner in line with timetables set by NHS England.

4. To ensure appropriate representation of the trust at any external decision making bodies.

5. Ensure records or logs are kept of gold command decisions or actions.

6. To consider the financial impacts on the trust of the major incident and, where necessary, make appropriate arrangements to maintain the financial integrity of the trust.

18.12.3 Chair

Chair: Chief operating officer

Deputy: Any other member of the executive group or OMG that has had or undergone joint decision model training.

18.12.4 Membership

This group comprises of strategic level representatives from teams likely to be integral to the response to the incident. Others may be added at the discretion of the accountable emergency officer (chief operating officer) or deputy. The gold command provides strategic leadership and its business should not be duplicated by the executive group. It does not provide tactical or operational level decision making.  It may comprise of the following:

  • chief executive
  • chief operating officer
  • director health informatics
  • executive medical director
  • head of estates and facilities
  • head of communications
  • director of strategy
  • executive director of nursing and allied health professionals and deputy chief executive
  • executive director of finance and performance
  • director of corporate assurance or board secretary
  • executive director for people and organisational development
  • clinical lead(s) as appropriate
  • business continuity and EPRR manager

In attendance:

  • care groups representatives (silver commanders)
  • human resources representative
  • loggist (required at all gold command meetings, either in person or remotely via MS Teams

If required to attend by invitation:

  • head of estates and facilities
  • information technology representative
  • information management clinical systems representative
  • finance representative
  • chief pharmacist
  • trust communications representative

In a lengthy incident deputies should be identified for all gold command roles.

Also, in a cyber or data security incident it is a legal requirement for the data protection officer to be informed and involved in all cyber, data security, or information incidents, in alignment with the trust cyber and data security incident plan.

Specialist subject cells may be established to provide reports and updates to gold command to inform decision making. These may comprise of other members of staff within the trust who are subject matter experts. Cells may cover subjects such as recovery, workforce and infection prevention and control.

18.12.5 Reporting arrangements

Reporting arrangements to external agencies can be found on page 10. Scale and frequency of internal reporting to and from silver and bronze commands is at the discretion of the trust gold command.

18.13 Appendix M Trust gold command initial agenda

18.14 Appendix N Service closure or adjustment to service delivery pro forma

18.15 Appendix O Gold command specialist subject cell highlight report

18.16 Appendix P Draft terms of reference for Trust care group silver command

18.16.1 Draft aims for silver command

  1. To provide a tactical command and control for the care group across all areas of business.
  2. To minimise disruption to care group services.
  3. To ensure a continued safe and caring environment for patients and staff.
  4. To ensure coordination of response with gold command.

18.16.2 Draft objectives for silver command

  1. To consider the impact on service delivery and ensure close liaison with bronze commanders (modern matrons, service managers).
  1. To ensure communications with staff, patients, partners and public are accurate, timely and are consistent with those issued by gold command and trust Communications team.
  1. To ensure situation reporting is conducted in a timely manner in line with timetables set by trust gold command.
  1. To ensure appropriate representation of the care group at any external decision making bodies such as tactical coordination groups and to liaise with gold to ensure coordinated representation.
  1. Ensure records or logs are kept of silver command decisions or actions.
  1. To consider the financial impacts on the care group of the incident and, where necessary, make appropriate arrangements to maintain the financial integrity of the care group.

18.16.3 Chair

Chair: Care group director.

Deputy: Care group nurse director, deputy care group director, corporate head of service or other senior member of staff that has had joint decision model training.

18.16.4 Membership

This group comprises of the silver commander and support from representatives likely to be integral to the response to the incident such as administrative staff and loggists. Others may be added at the discretion of the silver commander or deputy. The silver command provides tactical leadership. It does not provide strategic or operational level decision making. It may comprise of the following:

  • care group director
  • care group nurse director
  • care group medical director or lead consultant
  • corporate head of service
  • deputy care group director
  • representative from estates and facilities
  • representative from Communications team

In a lengthy incident deputies should be identified for all silver command roles.

Detailed actions cards exist in the major incident plan for gold command roles. Some of these, such as loggist, admin support and incident coordinator may be used by silver commands.

18.17 Appendix Q Care group silver command draft agenda

18.18 Appendix R Setting up a physical incident control centre

18.18.1 Setting up a face-to-face gold command incident control centre (ICC), Woodfield House, Boardroom 2

Actions to be taken by incident coordinator or admin support:

  • boardroom 2 of Woodfield House is the primary ICC for the trust for face to face meetings
  • important contact numbers:
  • in the event that boardroom 2 is needed for a trust gold command the following actions should be performed. Out of hours keys and alarm codes for Woodfield House can be obtained from TRH reception
  • make sure boardroom 2 is vacated if it is in use. Gold command takes precedence over other business
  • boardroom 1 is primarily to be used as a quiet room for formal meetings, this may also need to be vacated
  • ask reception staff (or admin if OOH) to inform anyone that has the room(s) booked to make alternative arrangements
  • equipment for gold command is stored in the large cupboard in boardroom 2 to the left of the TV screen. The key for the cupboard is stored behind reception on a hook and is clearly marked
  • equipment in the cupboard includes stationery and box folders containing various trust emergency plans
  • staff may use their soft phone on their laptop or mobile phone if extra numbers are required
  • draft agendas and terms of reference are contained with emergency plans and contacts in the box folders
  • instructions for using the TV are also contained in the box folders. A remote and batteries are contained in the emergency planning cupboard in boardroom 2
  • instructions for use of the MS Teams room big screen are also contained in the emergency planning cupboard in boardroom 2
  • in the event that MS Teams cannot be used then trust mobiles are to be used as the contingency
  • a list of service backup mobile numbers is available on the L Drive in the on call folder and in hard copy in the cupboard
  • should you wish to hold a telephone conference via mobile instructions are contained in the on call folder and in the emergency planning cupboard in boardroom 2
  • instructions for using the Microsoft Teams rooms equipment and software is contained in the emergency planning cupboard in boardroom 2

18.19 Appendix S Hot debrief template

18.20 Appendix T Training, exercise and incident record

Document control

  • Version: 3.1.
  • Unique reference number: 623.
  • Approved by: Corporate policy approval group.
  • Date approved: 21 December 2023.
  • Name of originator or author: EPRR manager.
  • Name of responsible individual: Accountable emergency officer or chief operator officer.
  • Date issued: 29 December 2023.
  • Review date: 30 September 2026.
  • Target audience: All staff.

Page last reviewed: April 30, 2024
Next review due: April 30, 2025

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