Our policies and procedures
Each Adverse Event is reported and reviewed via the Datix system. The procedure for reviewing each level of incident is set out in the Adverse Events Management policy. The Adverse Events Management policy and supporting tools/guidance have been updated to reflect the introduction of DoC.
The decision on DoC is built into the Significant Adverse Event Review (SAER) process. All severity 4 and 5 adverse events are automatically escalated as potential SAER. Legislation requires that a clinical person must make the final decision on Duty of Candour.
The Initial Assessment Tool (IAT) that supports review of SAERs is completed by the Clinical Governance Lead and/or Clinical Nurse Manager, depending on the type of event. This includes a specific question relating to the Duty of Candour status. The completed assessment and recommendation of Duty of Candour is then approved by the Division Management Team (DMT) which includes an Associate Nurse Director and Associate Medical Director. Any IATs that do not progress for review are discussed at the service Clinical Governance Forum with multi-disciplinary representation to ensure learning is captured and tis offers further opportunity for any challenge on the level of review and DoC status.
Each adverse event is reviewed with a focus on learning from what has happened, regardless of the level of harm. If there is potential to learn from an error this should be harnessed and taken forward. On completion of an adverse event, review actions are identified and these are monitored to completion via the Clinical Governance reporting framework.
All staff receive training on adverse event reporting and the implementation of DoC through corporate induction e-learning package. More in-depth training is delivered to those responsible for reviewing incidents on Datix. A programme of investigation training and supporting toolkit is being refreshed for staff who could potentially take part in a Significant Adverse Event investigation; this will take the form of blended learning utilising webinars, MS Teams sessions and in-person training where possible.
We know that being involved in a significant adverse event can be difficult for staff as well as those affected by the event. We have support available to staff in the form of the formal line management structure. In addition to this, the Spiritual Care Lead and the Occupational Health team are available to provide staff support in different forms following significant adverse events, where required. NHS Golden Jubilee staff also benefit from access to the TimeforTalking Employee Assistance Programme. This service works alongside the current range of health and wellbeing support available through NHS Golden Jubilee, both internally and externally and is available via telephone, online or face-to-face counselling for staff.
Further to this, patients/families are offered the support of our Spiritual Care Lead and clinicians where required.
