5. The trust’s Patient Safety Incident Response Plan: Nationally defined incidents for local PSII (National requirement)

5.1 Nationally defined incidents for local PSII are set within the Patient Safety Incident response Framework and are aligned to National Initiatives. These incidents are outlined in the table below along with the required response & planned improvement route.

 

Patient Safety Incident response Framework

Patient safety incident type

Required response

Anticipated improvement route

Lead organisation/body for a response

incidents meeting the Never Events criteria

Locally-led PSII

Create local organisational actions and feed these into the quality improvement strategy

CHS

Death thought more likely than not due to problems in care (incident meeting the learning from deaths criteria for patient safety incident investigations (PSIIs)

Locally-led PSII

Create local organisational actions and feed these into the quality improvement strategy

CHS

Maternity and neonatal incidents meeting Healthcare Safety Investigation Branch (HSIB) criteria or Special Healthcare Authority (SpHA) criteria when in place

Refer to HSIB or SpHA for independent PSII

Respond to recommendations as required and feed actions into the quality improvement strategy

HSIB (or SpHA)

Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity

Act (2005) applies, where there is reason to think

that the death may be linked to problems in care

(incidents meeting the learning from deaths criteria)

Locally-led PSII

Respond to recommendations as required and feed actions into the quality improvement strategy

CHS

Mental health-related homicides

Referred to the NHS England Regional Independent Investigation Team

(RIIT) for consideration for an independent PSII

Locally-led PSII may be required

Respond to recommendations as required and feed actions into the quality improvement strategy

As decided by

the RIIT

Child deaths

Refer for Child Death Overview Panel review

Locally-led PSII (or other response) may be required alongside the

panel review – organisations should liaise with the panel

Respond to recommendations as required and feed actions into the quality improvement strategy

Child Death

Overview Panel

Deaths of persons with learning disabilities

Refer for Learning Disability Mortality Review (LeDeR)

Locally-led PSII (or other response) may be required alongside the

LeDeR – organisations should liaise with this

Respond to recommendations as required and feed actions into the quality improvement strategy

LeDeR programme

Safeguarding incidents in which:

  • babies, children, or young people are on a child protection plan; looked after plan or a victim of wilful neglect or domestic  abuse/violence
  • adults (over 18 years old) are in receipt of care and support needs from their local authority • the incident relates to FGM, Prevent (radicalisation to terrorism), modern slavery and human trafficking or domestic abuse/violence

Refer to local authority safeguarding lead Healthcare organisations must contribute towards domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any other safeguarding reviews (and inquiries) as required to do so by the local safeguarding partnership (for children) and local safeguarding adults boards

Demonstrate compliance with statutory duties through the completion of CHS Individual Management Reviews and/or completion of other internal reports/processes/investigations as required. Learning and findings will feed into CHS Quality Improvement Strategy and processes.

CHS Safeguarding Team in partnership with Trust colleagues and Designated

Professionals for

child and adult

safeguarding

Incidents in NHS screening programmes

Refer to local screening quality assurance service for consideration of

locally-led learning response

https://www.gov.uk/government/publications/managing-safety-incidents-in-nhs-screening-programmes?msclkid=3ed7eeecbbe011eca69e287393777fd1

 

Respond to recommendations as required and feed actions into the quality improvement strategy

CHS

Deaths in custody (eg police custody, in prison, etc) where health provision is delivered by the NHS

Any death in prison or police custody will be referred (by the relevant

organisation) to the Prison and Probation Ombudsman (PPO) or the

Independent Office for Police Conduct (IOPC) to carry out the relevant

investigations

Healthcare organisations must fully support these investigations where

required to do so

Respond to recommendations as required and feed actions into the quality improvement strategy

PPO or IOPC

Domestic homicide

A domestic homicide is identified by the police usually in partnership with the community safety partnership (CSP) with whom the overall responsibility lies for establishing a review of the case.

Where the CSP considers that the criteria for a domestic homicide review (DHR) are met, it uses local contacts and requests the establishment of a DHR panel

The Domestic Violence, Crime and Victims Act 2004 sets out the statutory obligations and requirements of organisations and commissioners of health services in relation to DHRs

Respond to recommendations as required and feed actions into the quality improvement strategy

Community safety partnership (CSP)