Managing Health at Work Partnership Information Network (PIN) Guideline

This Guideline emphasises the need for employers to promote and support employee health and wellbeing and includes sections on issues that affect the health and safety of staff in their everyday work.


Checklist for a formal investigation

This process has been drawn up for clinical settings, but the same principles should be adapted for non-clinical settings.

Stage 1

An initial meeting should take place where possible within 72 hours of the incident, in order to:

  • review the circumstances surrounding the incident;

  • support those involved in the incident (staff, patients, relatives, visitors etc);

  • discuss and agree if there is a need for a formal review; and

  • set a date for the formal review.

This meeting should include the service manager and staff involved. In a clinical setting this meeting would also include the patient's GP or consultant.

Questions to be raised at stage 1:

1 Who will chair the formal review?
2 Who will make a record of the review?
3 What happened?
4 Was a staff member hurt? If so, what was the extent of the injury/ies?
5 What help was given to the staff members on duty during the incident?
6 Was a patient hurt? What was the extent of the injury/ies? What action was taken?
7 Have relatives been informed?
8 Were any visitors or non-Trust staff involved?
9 Was an incident form completed and a record made in the person's records?
10 Was the duty doctor and/or the person's consultant informed?
11 What is the person's care plan/safety care plan? Was it implemented? Did it work? Does it need to be reviewed?
12 Are there any service/resource/training implications?
13 Were other agencies involved? If yes, invite them to the stage 2 meeting.
14 Has the Lead Clinician/Nurse or Head of Clinical Services been alerted of any concerns about possible press response to the incident?
15 Is there a need for a stage 2 meeting? If yes, request Lead Clinician/Lead Nurse or Head of Clinical Services to nominate a Chairperson and inform the Organisation Audit Secretary.
16 Who should receive a copy of the record of the meeting?

At the end of the meeting, the convenor of the Stage 1 review is responsible for:

  • notifying the General Manager, Lead Clinician/Nurse or Head of Clinical Services of any immediate actions that need to be taken because of the incident; and

  • sending an initial report to the Clinical Risk Manager.

Stage 2

1 The stage 2 meeting should take place within 4-6 weeks of the incident.

2 A senior clinician or other appropriate person will chair the meeting, which will be recorded by the Clinical Office/Audit Secretary. It should involve the staff directly involved in the incident plus significant others who have responsibility for that part of the service or to the patient involved.

3 The minutes of the stage 1 meeting should be available and form the starting point for discussion which will expand to cover the following:

  • events leading up to the incident;

  • what happened during and after the incident;

  • person's care plan;

  • number of staff on duty;

  • level of staff on duty;

  • any shortages that may have contributed to the incident;

  • availability of staff at the time of incident;

  • environmental factors;

  • equipment failure;

  • needs of other patients present during the incident;

  • information and support needs of the family;

  • support needs of staff, including legal advice or representation, if appropriate;

  • any service/resource/training implications;

  • information to go to GP;

  • report to Clinical Risk Manager;

  • contacting the Central Legal Office if required; and

  • in the case of deaths, considering whether a Fatal Accident Inquiry is likely.

4 A record of the discussion and the outcomes of the review must be forwarded to:

  • the Clinical Board, where actions are identified; and

  • the Clinical Governance Group, to ensure a continuous audit of such incidents.

The Audit Secretary will retain a copy to maintain a central file of all serious incident reviews.

Stage 3

The minutes of the reviews will be audited annually to:

  • identify any repeated issues;

  • update the review process itself; and

  • adapt standards as necessary.

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