Incident management policy

1 Document summary

1.1 Purpose and scope

• Ensures timely reporting, management, and learning from all incidents (including near misses) to improve safety for patients, colleagues, and visitors.
• Applies to all colleagues, students, volunteers, contractors, and partner staff on trust premises.
• Aligns with National Patient Safety Incident Response Framework (PSIRF) and uses learn from patient safety events (LFPSE) system.
• Open and honest communication (duty of candour, moderate harm or above).
• System-based learning responses to prevent recurrence.
• Support for colleagues and families affected by incidents.
• Compliance with statutory reporting (for example Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), Medicines and Healthcare products Regulatory Agency (MHRA), Care Quality Commission (CQC).

1.2 What is an Incident?

Any event causing or with potential to cause harm, dissatisfaction, damage, or loss.

Includes:

• patient safety incidents, safeguarding concerns, colleagues incidents, non-person incidents, near misses, no-harm events
• all incidents must be logged on the electronic incident reporting system within 24 hours
• notification sent to designated managers and subject-matter experts
• graded by consequence and likelihood (risk matrix)
• timeframes for closure:
  • near miss and minor harm: 21 days
  • moderate harm: 28 days
  • severe harm or death: 60 days

Learning responses range from local review to full patient safety incident investigation (PSII).

1.2.1 Relationship between the incident management policy and the patient safety incident response policy and plan

Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH) manage incidents using two linked but distinct approaches. the incident management policy, and the patient safety incident response (PSIR) policy and plan, developed in line with the National Patient Safety Incident Response Framework (PSIRF). These policies have different purposes and must be used in a complementary but not interchangeable way.

1.3 External reporting

• Health and Safety Executive (HSE): Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), injuries, diseases, dangerous occurrences.
• Learn from patient safety events (LFPSE): all patient safety incidents.
• Medicines and Healthcare Products Regulatory Agency (MHRA): device and drug-related issues via yellow card.
• Care Quality Commission (CQC): detained patient deaths, absent without leave (AWOL), Deprivation of Liberty Safeguards (DoLS), child admissions to adult wards.
• Police, NHS Resolution, environmental health, coroner, learning from lives and deaths: people with a learning disability and autistic people (LeDeR) as applicable.
• Reporting safeguarding concern to a local authority and making safeguarding referrals to children’s social care.

1.4 Responsibilities

• Managers: ensure reporting, manage workflows, close incidents.
• Patient safety carer and community team: oversight, Patient Safety Incident Response Framework (PSIRF) compliance, learn from patient safety events (LFPSE) reporting.
• Health and Safety Lead: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) compliance; Mental Health Act Manager: Care Quality Commission (CQC) notifications.
• Safeguarding team have responsibility and oversight of all safeguarding incidents.

2 Introduction and aim

Responding appropriately to incidents or circumstances that have caused or may cause harm to patients, colleagues (including contracted colleagues) or visitors is central to how the trust continually improves safety. A clear reporting, management and review process enables timely action and effective learning.

The trust responds to and reviews patient safety incidents using the National Patient Safety Incident Response Framework (PSIRF). The National Patient Safety Incident Response Framework (PSIRF) sets out a proportionate, system‑based approach that focuses on compassionate engagement with those affected, uses a range of response methods, and strengthens oversight across providers and integrated care systems.

The trust records patient safety events through the national Learn from patient safety events service.

This policy sets out the trust’s systems, processes and expectations for:

• reporting incidents involving colleagues, patients and others
• open, honest communication and timely documentation
• statutory reporting to external agencies
• proportional, system‑based review and learning responses
• support for colleagues involved in or witnessing incidents
• alignment with learning from deaths policy and patient safety incident response plan
• governance, assurance to the board and information sharing with stakeholders
• training requirements and competencies

This policy applies to all colleagues, students, volunteers, contractors and employees of other organisations working on the trust’s estate.

3 Procedure

All incidents of all types, including near misses, must be reported via the incident reporting system. Where in doubt, colleagues should seek advice from their manager, Health and Safety lead or relevant director without delay.

3.1 What is an incident?

It also includes incidents resulting from negligent acts, deliberate or unforeseen.

Illustrative examples include unexpected or unexplained death, absconding of a detained patient, colleague injury, abuse against colleagues, public falls on trust premises, fire, theft or damage, and safeguarding concerns.

All untoward and unexpected occurrences should be reported on the incident reporting system.

3.2 Who is responsible for reporting incidents?

The colleague involved should report to a senior manager and on the incident system. The senior person on duty must ensure reporting takes place. Service managers must confirm that reports are submitted.

3.3 How to report an incident

The incident reporting system is a web system used across the trust for all incidents, unexpected occurrences and concerns. Guides are available and support can be requested from the Patient Safety, Community and Carer team at rdash.patientsafetyteam@nhs.net.

If an incident requires an urgent response or is serious in nature, the manager or duty manager should be contacted immediately, and an incident form entered as soon as practicable. Incidents should be reported as soon as practicable and within 24 hours of the incident occurring or colleagues becoming aware.

3.4 Incident grading

All incidents need to be screened to identify the appropriate level of learning response using the risk matrix based on consequence and likelihood. The risk score supports the decision on learning response level, alongside patient safety incident response plan (PSIRP), external requirements and reputational considerations. Duty of candour is triggered by actual harm at moderate level or above.

This risk scoring is separate to the “actual impact” score used to determine if an incident requires duty of candour (refer to being open and duty of candour policy for more details). The “actual impact” score covers both physical and psychological harm. Duty of candour is triggered by actual harm at moderate level or above.

3.4.1 Level of harm

Near miss, example incidents:

• I observed the patient was walking towards some water spilt on the floor in her room. I diverted her away from the spillage in case she would fall and cleaned up the water to make the floor safe
• a patient was observed starting to tie a shoelace around their neck, the potential ligature was removed

No harm or insignificant, example incidents:

• the temperature in the office reached 29.5 degrees and made working conditions unbearable
• during depot administration the prefilled syringe neck snapped which rendered the injection unusable but caused minimum stress or delay for the patient

Minor harm, example incidents:

• pressure ulcer category 2
• during prevention and management of violence and aggression (PMVA) training a colleague became off balance and pressed on facilitator’s back causing pain and discomfort

Moderate harm, example incidents:

• patient self-harmed with a broken glass bottle resulting in a visit to accident and emergency and surgery
• patient was found on floor and x-ray found arm fracture

Major harm, example incidents:

• I called a patient and he told me had taken an overdose of paracetamol, I asked another colleague to contact an ambulance whilst I continued talking to the patient
• a patient attacked a colleague with a knife resulting in surgery

Catastrophic, example incidents:

• a patient was found to have a grenade, the premises were evacuated, and bomb disposal squad called
• a fire broke out in a treatment room, the area was evacuated successfully, and the fire service attended however the building was destroyed

Mortality incidents:

• a patient committed suicide
• a patient died from physical health concerns

3.5 Who receives notification of an incident?

On submission, the system emails the summary to pre‑designated managers and subject‑matter experts. For incidents resulting in moderate harm or above, summaries are sent to the listed clinical and corporate recipients:

• relevant care group colleague, deputy care group directors, heads of service and corporate heads of services
• trust medical devices and duty of candour officer
• Patient Safety, Carer and Community team
• deputy chief nursing officer
• head of quality and promises
• professional leads for the clinical profession (for example, occupational therapy)

3.6 What to do when you receive e-mail notification of an incident or occurrence

3.6.1 Designated incident manager

The manager accesses their incidents list, checks and amends details, and completes assigned workflows. Responsibilities include managing and closing the incident on the system.

3.6.2 The subject-matter expert

Each incident is forwarded to relevant experts such as security, falls prevention, resuscitation and safeguarding. The expert reads the report, provides guidance and may seek further information or carry out a learning response.

3.7 What are the time periods for incident management?

Learning responses should be completed and incidents closed in the system within 21 working days for near miss to minor harm, 28 days for moderate harm and 60 days for severe harm or death, unless complexity or delays require extension. Where an incident proceeds to a patient safety incident investigation (PSII), or external investigations by police, coroner or other statutory bodies, managers should close the incident and note the external process.

3.8 Duty of candour

The trust must act in an open and transparent way, notify the relevant person as soon as reasonably practicable after becoming aware of a notifiable patient safety incident, provide a factual account, advise on enquiries, offer an apology, follow up in writing and keep a written record.

The trust’s being open policy (incorporating duty of candour) is available and details the policy and procedures required for meeting the duty.

3.9 The trust’s external reporting arrangements

The trust reports certain types of incidents to external agencies. The health and safety lead scrutinises reports to ensure all relevant notifications are made to the health and safety executive.

The main external agencies to which the trust reports incidents are listed below (please note this is not an exhaustive list, and advice will be taken by the health and safety lead in conjunction with other relevant managers, on particular issues).

3.9.1 Reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR) 2013 (appendix C)

Reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR) requires reporting specified incidents to the Health and Safety Executive. Common reports include injuries resulting in more than seven consecutive days absence, certain dangerous occurrences and diagnosed occupational diseases. The Health and Safety Executive has updated guidance to clarify when and how to report, with improved online forms and explanations on work related accidents and over seven-day reporting. The health and safety lead will report as required following the Health and Safety Executive guidance and will attach relevant reports to the incident form.

3.9.2 Learn from patient safety events (LFPSE) service

Patient safety incident information is submitted through the incident reporting system to learn from patient safety events. The national reporting and learning system was decommissioned on 30 June 2024 and organisations use learn from patient safety events (LFPSE) compliant systems or the online service. Relevant staff in integrated care boards and regions may access data for oversight.

3.9.3 Medicines and Healthcare Products Regulatory Agency (MHRA)

Incidents relating to medical equipment or suspected adverse drug reactions should be notified to the Medicines and Healthcare Products Regulatory Agency via the yellow card service website or app. This includes medicines, vaccines, devices and e‑cigarettes.

3.9.4 NHS Resolution

Incidents where there are likely to be civil claims require, where practicable, to be notified to NHS Resolution as early as possible.

Managers should inform the claims team about all claims supported by the submission of an electronic incident form where appropriate to enable as much information to be gathered prior to reporting the claim as possible.

The trust claims team will contact NHS Resolution as appropriate.

3.9.5 Environmental health office and Food Standards Agency

Incidents relating to food will, in addition to being notified internally using the electronic incident reporting system, be notified to the local environmental health office of the local authority and the Food Standards Agency by the catering manager.

3.9.6 Police

Criminal incidents should be reported to the police. Colleagues can dial 101, or 999 for emergencies. Complete an electronic incident form for all incidents reported to the police.

3.9.7 NHS Improvement

NHS Improvement has a statutory duty to assess, authorise and regulate NHS foundation trusts. Incidents of concern are highlighted to NHS Improvement by the chief executive officer, or trust board secretary as required.

3.9.8 Care Quality Commission (CQC), mental health notifications

Incidents to be reported to Care Quality Commission:

• the death of a patient detained or liable to be detained under the Mental Health Act (1983)
• the unauthorised absence of a patient detained or liable to be detained under the Mental Health Act (1983) from a secure ward
• any application and outcome made to a supervisory body in relation to depriving a service user of their liberty
• the admission of a child or young person to an adult psychiatric ward or unit
• trust policy to be referred to for full detail of reporting:
  • learning from deaths policy
  • patients missing or absent without leave (AWOL) policy
  • Mental Capacity Act Deprivation of Liberty (DoL) policy
  • care and treatment of children under the age of 18 on adult acute mental health inpatient areas policy
• Details of regulations under which this reporting is required:
  • regulation 17 of the Care Quality Commission (Registration) Regulations (2009)
  • regulation 18 of the Care Quality Commission (Registration) Regulations (2009)

The following must be reported directly to the Care Quality Commission without delay (or on next working day after a weekend or bank holiday):

• for deaths of detained patients and the admission of a child or young person to an adult psychiatric ward or unit, the mental health act manager is responsible for notifying the Care Quality Commission
• for service users who are absent without leave from a secure ward, the nurse in charge is responsible for notifying the Care Quality Commission, see patients missing or absent without leave (AWOL) policy

3.9.9 Regulatory bodies for professionals

Reporting to the General Medical Council (GMC), Nursing and Midwifery Council (NMC), Health and Care Professions Council (HCPC) is managed under the employment policies by the human resources department with relevant senior managers.

3.9.10 Practitioner Performance Advice (formerly National Clinical Assessment Service (NCAS))

Referrals for advice on resolving performance concerns about doctors, dentists and pharmacists are managed by human resources with senior leaders. Practitioner Performance Advice is part of NHS Resolution and provides advice, assessment, interventions and training

3.9.11 NHS Counter Fraud Authority (formerly NHS protect)

Incidents of fraud, bribery and corruption should be reported via the local counter fraud specialist. For further guidance see the counter fraud, bribery and corruption policy.

3.9.12 Information commissioner

Colleagues should refer to the data security and protection breaches or information governance incident reporting policy.

3.9.13 Coroner’s office

Statutory duties to refer deaths to the local coroner apply as set out in this policy (see appendix A). Where in doubt seek guidance from the coroner’s office.

3.9.14 Death of a person with a learning disability

Deaths of patients with a diagnosis of learning disability must be reported to learning from lives and deaths: people with a learning disability and autistic people (LeDeR) via the online reporting tool in line with local integrated care system arrangements and national programme guidance. A local review is to be completed as soon as practicable using the mortality review.

3.10 Learning response process

3.10.1 Mortality reviews

The trust’s learning from deaths policy sets out review requirements. All deaths for which the trust is the main provider should be reported using the incident reporting system. The approach includes structured judgement review where indicated. This supports board assurance that deaths are effectively reviewed.

Requirements are detailed within the learning from deaths policy the right thing to do.

3.10.2 Review of trust acquired pressure ulcers graded at level 3 or above

Where a trust acquired pressure ulcer is assessed as category three or above, complete a review to determine cause, learning and whether a patient safety incident investigation is required.

Pressure ulcers present on admission are reviewed by the agency where they originated. For full guidance colleagues are to refer to the trust pressure ulcers, prevention detection, and treatment procedure within the wound care and tissue viability manual.

3.10.3 Incidents rated low which don’t reach the duty of candour threshold

Low rated incidents are reviewed and managed within the service. Managers verify grading, actions and record outcomes, escalate themes for structured review when indicated, and document learning.

3.10.3.1 Review of non-clinical incidents

Managers ensure proportionate learning response and remedial actions. Reportable incidents under reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR) are notified to Health and Safety Executive. The Health and Safety team supports managers on complex matters.

3.10.5 Guidance on the preservation or recording of evidence

3.10.5.1 Key principle

Evidence is preserved only to the level required by law or other formal processes.

For Patient Safety Incident Response Framework (PSIRF), information is recorded only where necessary to support learning and improvement.

3.10.6 Action to take if, during the course of a learning response concerns are identified in relation to a colleague’s clinical practice, behaviour, or attitude

Notify the person’s line manager and relevant senior leads immediately and follow professional lead processes. Notify agencies for agency colleagues.

3.10.7 Undertaking a learning response which is also subject to a police investigation

Avoid actions that could taint police evidence. Liaise with named officers and proceed with permitted record reviews and interviews, documenting all contact.

3.10.8 Conducting learning responses when other health care providers are also involved

Aim for single learning responses across organisations. Where separate learning responses are necessary, share issues identified related to partner processes or actions. There could also be other agencies involved such as when a safeguarding adult review, domestic abuse related death review or child safeguarding practice review, which will require an additional response requested by these agencies.

3.10.9 Management of an incident learning response which is also subject to a formal complaint

Undertake one learning response that informs both the incident report and complaint response. Agree with the complainant what will be covered and advise on timeframes.

3.10.10 Serious health and safety incidents

Report via the incident system and to Health and Safety Executive where required by the health and safety lead only. Criteria include deaths, specified injuries, over seven-day incapacitation, occupational diseases and dangerous occurrences arising from work activities.

3.11 Incident action plans

3.11.1 Action plan development

Care group director or learning response lead submits an action plan following learning responses. Actions must be specific, measurable, achievable, realistic and timely.

3.11.2 Monitoring of action plan implementation

Action plans in the incident system alert leads to deadlines, remain open until all actions are complete and issue reminders.

3.11.3 Reporting of action plan implementation

Compliance is reported to the quality committee monthly in the serious incident report.

3.11.4 Process for the sign-off of homicide action plans

Central filing, evidence collation, service visits, briefing reports and committee sign off remain as set out to provide assurance.

3.12 Involving relatives and carers in learning responses

Where duty of candour or patient safety incident investigation applies, the lead engages the person and family, agrees contact preferences, updates at agreed times, addresses questions and feeds back outcomes. Use the Patient and family guide where helpful.

3.13 Support to colleagues involved in an incident

3.13.1 Immediate support

The senior person on duty identifies immediate support needs, including first aid, emergency care, staffing support and arrangements to leave duty where required.

3.13.2 Addressing psychological support needs

Provide reflective sessions, debriefs, occupational health support, spiritual care, personal safety planning and specialist trainer support for restraint or resuscitation incidents.

3.14 Support to other service users who may be affected by the incident

Offer opportunities to talk, agree support, review risk assessments and consider potential copying risks.

3.15 Support to relatives and carers

Nominate a senior colleague to communicate with the person or family. Consider advocacy, interpreters, local support groups and referrals for bereavement or anxiety. Alert care coordinators where relatives are in trust services.

If required, the booklet “patient safety incident investigation: patient and family guide” can be used. This explains what to expect and how patients and families can be involved in the process.

3.16 Learning from incidents

Extract learning at all levels and share flexibly across the trust and with external agencies, including commissioners where appropriate. Also refer to appendix D.

3.17 Dealing with media enquiries

The communications team prepares statements and coordinates frequency and content with relevant directors.

3.18 Colleagues who wish to raise a concern

Record details and raise concerns with a manager or refer to freedom to speak up policy for guidance.

3.19 Service to service issues

When trust colleagues report incidents involving external organisations, these are logged on the incident reporting system. The relevant team manager sends a service-to-service form to the appropriate trust or practice and copies in the Patient Safety team, who monitor the process via a spreadsheet. Responses are returned to the team manager and attached to the incident record. Learning is shared through care group meetings, the learn from patient safety events group, or the weekly patient safety huddle.

Other trusts may raise concerns about trust practices directly with the Patient Safety team. These are logged and forwarded to the relevant trust manager for response. Learning is shared in the same forums as above.

Issues raised by GP practices are dealt with by the GP Liaison team.

4 Responsibilities

• Chief nurse, deputy chief nurse and patient safety leadership: oversees Patient Safety Incident Response Framework (PSIRF) implementation across care groups and interfaces with integrated care boards and patient safety partners.
• Patient safety weekly incident huddle and oversight group: supports continuous learning responses and patient safety incident investigation approvals in line with Patient Safety Incident Response Framework (PSIRF).
• Patient safety, community and carer team: day-to-day operation of patient safety incident management including incident reporting system, advice and support, analysis of the data and reporting of trust-wide overview and trends, timescales and learning through agreed trust groups and committees.
• Health and safety lead: applies updated reporting of injuries, diseases and dangerous occurrence regulations (RIDDOR) guidance and timeframes.
• Data protection officer or head of information governance: uses Data Security and Protection (DSP) Toolkit for incident reporting and assures UK General Data Protection Regulation (GDPR) compliance.
• Mental Health Act manager: notifies Care Quality Commission as required by Regulation 17 and uses current Care Quality Commission portal and forms.
• Equality, diversity and inclusion responsibilities: all leaders must demonstrate due regard to the Public Sector Equality Duty and Accessible Information Standard in incident communication and support.

5 Training

It is important that colleagues involved in incident management are familiar with this policy and its purpose and rigorously apply procedures.

5.1 A system approach and human factors

Patient Safety Incident Response Framework (PSIRF) emphasises system‑based learning responses that minimise human error opportunities and build reliability.

5.2 Types of behaviour

5.2.1 Normal error (human error) (support)

Inadvertent action such as a slip, lapse, or mistake. Manage by changing:

• processes
• procedures
• design
• environment

5.2.2 At-risk behaviour (coach)

Individual is not educated about potential risk and sees no value in established policies to prevent it. Manage by:

• removing incentives for at-risk behaviours
• creating incentives for positive behaviours
• educate about potential risks
• redesign of system factors

5.2.3 Reckless behaviour (sanction)

Conscious and deliberate violations of procedures and policies. Manage through:

• remedial action
• punitive action

6 Monitoring arrangements

This section sets out how the trust will assure itself that the incident management policy is being implemented consistently and is working effectively in practice.

6.1 What will be monitored

The trust will monitor:

• volume and type of incidents reported, including patient safety incidents, near misses and no harm events
• timeliness of incident reporting and closure against agreed timeframes
• compliance with duty of candour requirements
• appropriateness and proportionality of learning responses in line with the Patient Safety Incident Response Framework (PSIRF)
• completion and implementation of action plans arising from learning responses
• themes, trends and recurring risks across care groups
• evidence that learning has been shared and acted upon

6.2 How monitoring will take place

Monitoring will be undertaken through:

• routine analysis of incident data from the incident reporting system
• review of learning response quality and action plans
• thematic reviews and trust wide trend analysis
• oversight through established governance groups

6.3 Reporting and escalation

Monitoring information will be reported as follows:

• monthly patient safety reports to the Patient Safety Operational Group
• escalated risks, themes or concerns to the Quality and Safety Group
• significant concerns escalated to the trust board through established assurance routes

Where monitoring identifies:

• delays in incident management
• repeated themes with insufficient improvement
• gaps in duty of candour or learning responses

These will be escalated for action and, where required, addressed through improvement plans, additional learning responses or leadership review.

6.4 How the trust knows the policy is working

The trust will know the policy is effective through:

• sustained reporting of incidents and near misses
• timely closure of incidents and learning responses
• evidence of learning leading to changes in practice
• reduction in repeat or preventable incidents where learning has been applied
• assurance reports demonstrating oversight and improvement

7 Related documents

• Being open policy
• Claims handling policy
• Clinical risk assessment and management policy
• Listening and responding to concerns and complaints policy
• Mental Capacity Act (2005) Deprivation of Liberty (DoL) policy
• Disciplinary policy
• Freedom to speak up policy, raising concerns (whistleblowing) policy
• Health and safety policy
• Healthy workplaces staff support and stress at work policy
• Mental Capacity Act (2005) policy
• Safe and secure handling of medicines manual
• Safeguarding adults policy
• Safeguarding children policy
• Care Quality Commission, (2015). Guidance for providers on meeting the regulations.
• Dangerous Drugs, England, and Scotland, Instrument No. 3148 The Controlled Drugs (Supervision of Management and Use) Regulations 2006.
• NHS England (2022) Patient Safety Incident Response Framework
• NHS Improvement, (2018). Never Events Policy and Framework and Never Events List (2021)

8 Appendices

8.1 Appendix A mortality reporting and review process

8.1.1 All deaths

1. Report on incident reporting system under mortality event.
2. Manager informed.
3. Check for statutory and coroner requirements:
   • suicide or death within 6 months of discharge
   • Mental Health Act or Deprivation of Liberty Safeguards
   • under 18
   • occupational injury
4. If yes:
   • notify coroner
   • escalate to Patient Safety team (within 24 hours)
5. If no:
   • is the death expected and natural?
   • band 7 and above review
6. If no concerns identified:
   • document review completed
   • close incident
7. If concerns identified:
   • structured judgement review
   • patient safety response decision from the learn from patient safety events (LFPSE)
8. Learning completed:
   • actions logged
   • mortality event closed

8.2 Appendix B Definition of never events (2018), revised 2021

8.2.1 Surgical

• Wrong site surgery.
• Wrong implant or prosthesis.
• Retained foreign object post procedure.

8.2.2 Medication

• Mis-selection of a strong potassium solution.
• Administration of medication by the wrong route.
• Overdose of insulin due to abbreviations or incorrect device.
• Overdose of methotrexate for non-cancer treatment.
• Mis-selection of high strength midazolam during conscious sedation.

8.2.3 Mental health

Failure to install functional collapsible shower or curtain rails.

8.2.4 General

• Falls from poorly restricted windows.
• Chest or neck entrapment in bed rails.
• Transfusion or transplantation of ABO-incompatible blood components or organs
• Misplaced naso-gastric tubes or oro-gastric tubes.
• Scalding of patients.
• Unintentional connection of a patient requiring oxygen to an air flowmeter.
• Undetected oesophageal intubation (temporarily suspended as a never event).

8.3 Appendix C

Non-clinical accident or incident, an event or circumstance that could have (for example, near miss) or did cause unexpected or unwanted harm, loss or damage to any individual(s) involved including service users (but not related to clinical care), colleagues, visitors) or damage to or loss of property or premises for which the trust is responsible.

• Fatalities (non-clinical) related to work activities.
• Specified injuries, including bone fractures (except fingers, thumbs, and toes), limb amputations, serious burns.
• Over 7-day injuries, colleagues absent from work for more than 7 days (including non-workdays, but excluding the day of the accident)
• Occupational diseases, work-related and medically diagnosed.
• Dangerous occurrences, for example collapse of lifting equipment.

For an accident to be reportable under RIDDOR it must meet 2 criteria:

• It must be work-related
• It results in a reportable injury

8.3.1 Non-clinical incident occurs, employee

Fatality:

1. notify Health and Safety Executive (HSE) immediately by phone (person at incident location)
2. person involved in accident or manager to contact Health and Safety team as soon as possible with details of the incident
3. Health and Safety team to report to Health and Safety Executive within 10 days
4. complete an incident report

Specified injury:

1. person involved in accident or manager to contact Health and Safety team as soon as possible with details of the incident
2. Health and Safety team to report to Health and Safety Executive within 10 days
3. complete an incident report

Not a specified injury:

1. person involved in accident or manager to contact Health and Safety team as soon as possible with details of the incident
2. Health and Safety team to report to Health and Safety Executive within 15 days
3. complete an incident report

8.3.2 Non-clinical incident occurs, non-employee visitor, contractor, or patient (not as a result of clinical treatment) injured on trust premises or by work under trust’s control

Fatality:

• notify Health and Safety Executive immediately by phone (person at incident location)
• person involved in accident or manager to contact Health and Safety team as soon as possible with details of the incident
• Health and Safety team to report to Health and Safety Executive within 10 days
• complete and incident report

Injured person taken from accident site directly to hospital:

1. person involved in accident or manager to contact Health and Safety team as soon as possible with details of the incident
2. Health and Safety team to report to Health and Safety Executive within 15 days
3. complete an incident report

8.4 Appendix D quick reference guide to incident reporting or learning response

8.4.1 Pressure ulcer grade 3 or above

1. Report as an incident on the incident reporting system.
2. Review undertaken by the service or ward manager; if unavoidable, log any actions on incident system.
3. If determined avoidable, does it meet threshold for safeguarding alert?

8.4.2 Fall

Report as an incident on the incident reporting system.

8.4.3 Death due to any cause

Report as a mortality on the incident reporting system, review takes place by mortality operational group, learning response route determined, taken to learn from patient safety events (LFPSE) group if potential patient safety incident investigation (PSII), report and actions logged on electronic system.

8.4.4 Harm due to other reasons for example, patient accident, equipment failure or significant self-harm

1. Report as an incident on the incident reporting system.
2. Learning response route determined, and if a potential patient safety incident investigation has occurred.

Page last reviewed: May 28, 2026
Next review due: May 28, 2027

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