HASCAS - The Health and Social Care Advisory Service

Dealing with Serious Untoward Incidents

HASCAS can help you deal with the investigation of SUIs and in auditing the result of investigations.

We have developed a Project Plan for the investigation of SUIs which will enable your staff to get on with their usual work without having to undertake the coordination work necessary to conduct an internal investigation - as we will act as Project Manager.

We have also developed an Audit Tool to examine how well the investigation has been conducted and whether it was done in the spirit of learning the lessons and keeping an open mind.

Audit Tool for Reviewing the Quality of Internal Review Reports

The aim of the tool is to:

assess whether reviews conform to the Root Cause Analysis (RCA) process;
improve the quality of the review process and output;
provide information about the impact of RCA training and highlight further training needs.

For this audit process a serious untoward incident ( SUI ) is defined as any incident:

involving NHS patients and other people with known mental health problems, their relatives or visitors, or staff or students responsible for them;
that could have or did lead to serious harm or damage relating to service users, members of staff, the public or Trust property;
that occurred in any setting, including NHS, local authority and independent sector mental health settings, and in user’s and carer’s homes.

The review report is a document investigating an incident or series of incidents that aims to establish what exactly happened, why the incident occurred, and what lessons need to be incorporated into future practice. Reviews incorporate both information gathered at the time and from the scene of the incident(s), and information gathered as soon as practicable after the incident and from other sources. The focus of this audit tool is the review report, and the information on the review process contained in it.

The audit tool includes:

A basic information checklist regarding the report itself
Seven audit categories. For each audit category, an expanded audit statement indicates the overall standard that should be met, and a number of more specific criterion statements are given
A summary of any positive practice highlighted by the report that should be disseminated
A supplementary optional audit tool for reviewing completion of the initial incident form

The seven audit categories are:

Reporting of the incident
Establishing the review process
Undertaking the review
Analysis
Corrective actions developed and implemented
Clarity over accountability and responsibility for action
The report

The last section (section 8) asks for a description of any positive practice highlighted by the report.

Learning Tools for those Dealing with SUIs and affected by them

The aftermath of a serious untoward incident, such as suicide or homicide, for those affected can have far reaching consequences. In particular such incidents will disrupt the lives of families and carers and may have a negative impact on the mental health of those involved, including staff and other service users. The response of organisations, mental health services, the police, the coroner and the media will influence people’s experience following an incident, and it is therefore important to harness the opportunity afforded by their role to facilitate recovery.

HASACAS has developed the following products which offer help in dealing with these difficult areas of work:

A framework for the process for those affected by a serious incident including families and carers, service users and staff, building on local policies, the experiences of families, carers, staff and other service users.
Training materials to support the implementation of the framework for good practice in response to a serious incident.

For more information please contact:

IAN ALLURED

0207 307 2892