Healios DoC Process

Duty of Candour

Incident management

Event is identified

1

Notification

2

3

Being Open principles

4

Serious incidents

Grading of incident

5

AT HEALIOS

Notification

2

Event is identified

Grading of incident

1

3

Being Open principles

4

Serious incidents

5

All incidents or near misses must be reported at the time of the event, or within 24 hours. They must be reported using the Incident Form on the Knowledge Centre. Incidents can include:

• Clinical safety incidents
• Accidents
• Near misses
• Security incidents
• Equipment/software failure
• Informatin governance incidents
• Violence
• Fire or alarms

Event is identified

Access the Incident Form

All reports made through the Incident Form are added to the Incident Log which is reviewed throughout each day. The relevant department head (non-clinical) or service manager (clinical) will be automatically notified.

Notification

2

Event is identified

1

Grading of incident

Notification

3

Being Open principles

4

Serious incidents

5

The notified person is required to grade the incident using a RAG (red, amber, green) rating. Clinical/patient safety incidents require a verifcation meeting between the service, service manager and the governance team. One outcome of this meeting will be to establish the level of harm attributed to the incident:

• For no or low harm incidents, the Being Open principles should be followed.
• For moderate to severe harm events, a full Duty of Candour will be triggered.

For clinical/patent safety incidents, if there is uncertainty over the RAG rating, the incident should be escalated to the Head of Service Quality.

Grading of incident

2

Event is identified

1

Grading of incident

Notification

3

Being Open principles

4

Serious incidents

5

RAG rating information

All incidents should be followed-up in line with the principles of Being Open. These principles are:

1. Principle of Acknowledgement
2. Principles of Truthfulness, Timeliness and Clarity of Communication
3. Principle of Apology
4. Principle of Recognising Client and Carer Expectations
5. Principle of Professional Support
6. Principle of Risk Management and Systems Improvement
7. Principle of Multidisciplinary Responsibility
8. Principle of Clinical Governance
9. Principle of Confidentiality
10. Principle of Continuity of Care

Being Open principles

2

Event is identified

1

Read more about the Being Open Principles in the Duty of Candour Policy (Appendix 3)

Grading of incident

Notification

3

Being Open principles

4

Serious incidents

5

Serious incidents are those that are rated red. Serious incidents always require an investigation. An initial investigation is required within 72 hours. This process is led by the Governance team.A serious incident may also meet the threshold for a Duty of Candour depending on the level of harm attributed to the incident. If the incident does trigger a Duty of Candour, specific actions and timescales must be adhered to in line with Duty of Candour regulations.

Serious incidents

2

Event is identified

1

Grading of incident

Notification

3

Being Open principles

4

Serious incidents

5

Managing Non-clinical Incidents SOP

Duty of Candour: actions and timescales

Managing Clinical Incidents SOP

Select to see more information.

Green (low)Description: no or low harm caused by or to Healios.Action: Dept. manager/service manager will review the incident form and is responsible for completing the post-report actions. No investigation required.Amber (medium)Description: potential harm caused to Healios/client.Action: Dept./service manager to identify trends and escalate to relevant team leads/clinical risk manager for discussion. May not require an investigation. Red (serious)Description: harm caused to the client, data released outside of business, major technical failure, high clinical risk.Action: Investigation always required. See the serious incident section.

RAG ratings

1. Identify responsible Duty of Candour LeadThe Investigation Lead will be the responsible Duty of Candour Lead. The investigation should be commenced within 10 working days of the notification.2. Duty of Candour conversationThe Investigation Lead should consider holding a face-to-face via video conference Duty of Candour conversation with the client and/or their carers.3. Written apology and notificationA written summary of the candour discussion must be forwarded to the client or family/carers as soon as is practicably possible.

actions and timescales

Duty of Candour:

4. Incident investigationThe investigation should be completed within 28 working days.5. ReviewIncidents will be reviewed with the operational lead and the Quality and Governance Team.6. Investigation complete and apologyWithin 10 working days of the investigation being completed and following approval, the letter and report are sent to the client or representative from the the Investigation Lead.7. Lessons LearnedThe Clinical Governance Team will communicate with all staff regarding learning.