PUTTING THINGS RIGHT dealing with concerns

Llywodraethu dacalon iechyd da

Good governanceat the heart of good health care
GUIDANCE ON THE REPORTING AND HANDLING OF SERIOUS
INCIDENTS AND OTHER PATIENT RELATED CONCERNS / NO
SURPRISES
Background
The existing NHS Wales serious incident (SI) reporting requirements have been in place
since April 2003 (Reporting of Patient-Related Serious Adverse Incidents letter issued by
John Hill-Tout). In addition to the SI process, all NHS organisations are required to report
all patient safety incidents (irrespective of seriousness and degree of harm) to the National
Patient Safety Agency (NPSAs) Reporting and Learning System (RLS). This is to inform
the prioritisation and development of safety solutions, including rapid response reports and
alerts, in addition to contributing to data which is published on a national and
organisational basis.
The reporting of SIs to the Welsh Assembly Government and NPSA does not exclude the
requirement to report to other bodies, e.g. Healthcare Inspectorate Wales, Health & Safety
Executive (RIDDOR), Information Commissioners Office, Police, Coroner, as appropriate
and as required by each individual body.

Definitions
The definition of a SI in this context extends beyond those which impact directly on
patients. The NPSA has suggested the following definition which we would wish to adopt
in NHS Wales:
A SI requiring investigation is defined as an incident that occurred in relation to NHS
funded services and care resulting in:

the unexpected or avoidable death of one or more patients, staff, visitors or

members of the public;

permanent harm to one or more patients, staff, visitors or members of the public or
where the outcome requires life-saving intervention or major surgical/medical
intervention or will shorten life expectancy (this includes incidents graded under the
NPSA definition of severe harm);

a scenario that prevents or threatens to prevent an organisations ability to continue

to deliver health care services, for example, actual or potential loss or damage to
property, reputation or the environment;

a person suffering from abuse;

adverse media coverage or public concern for the organisation or the wider NHS;

the core set of Never events as updated on an annual

http://www.nrls.npsa.nhs.uk/resources/collections/never-events/core-list/
2010/11 this includes: wrong site surgery
retained instrument post-operation
1

basis.
For

 wrong route administration of chemotherapy

misplaced naso-gastric or orogastric tube not detected prior to use
inpatient suicide using non-collapsible rails
escape from within the secure perimeter of medium or high security mental
health services by patients who are transferred prisoners
in-hospital maternal death from post-partum haemorrhage after elective
caesarean section
intravenous administration of mis-selected concentrated potassium chloride

Reporting arrangements for reporting serious incidents and other

concerns/no surprises to the Welsh Assembly Government
Since April 2010, all serious incidents or no surprises (sensitive issues) have been
reported, electronically, to the Improving Patient Safety Team Mailbox at the Assembly
Government.
NHS Organisations are now required to:

Complete a revised SI notification form (form 1) for the reporting of all serious
incidents (attached at appendix 1) or complete form 2 for the reporting of no
surprises (attached at appendix 2). Please note the forms are protected so that the
title of the form and the text prompt boxes can not be altered. The field boxes in
bold that are completely grey are for Welsh Assembly Government use only;

Ensure that the notification form provides as much information as is available.

However, please ensure at all times that there are no patient or staff identifiable
details (e.g. patient name, dates of birth, home address, staff names etc);

Send the completed notification form to improvingpatientsafety@wales.gsi.gov.uk

within 24 hours of the incident;

Password protect each notification form;

Ensure that each notification form is signed off by the CEO or an Executive
Director. An electronic signature should be attached to the form.

Please note: Notification forms will be sent back to the organisation if there is no
executive sign off or if it is not password protected.
Within 24 hours of receipt, the Assembly Government will respond to the notification by
returning an electronic copy of the SI form which will confirm:

The initial grading of the incident which will indicate the timescale of investigation
(as defined below); and,

The Assembly Government reference number, which will be the number used in all
future correspondence relating to the incident.

For incidents that potentially may attract national or significant media attention, please
immediately contact a member of the Improving Patient Safety Team (IPST), who will
liaise with the Assembly Government Press Office. Appendix 3 indicates the contacts
2

detail of Assembly Government officials within the IPST for your organisations. Direct
contact should only be made with the Assembly Government Press Office out of usual
working hours. The out-of-hours press office number is 029 2089 8099 and the answer
phone will give the contact number of the duty press officer.

Grading of Incidents
The initial grading of a SI is undertaken on a case by case basis and will clarify the level of
investigation required and monitoring approach by the Assembly Government. All
incidents submitted to the Assembly Government are reviewed on a weekly basis. If
during these review meetings it is decided that the initial grading is inappropriate, it will be
revised and you will be informed of this change, plus any further action or information that
we may require.
Should an organisation wish to discuss the grading assigned to an incident they should
contact the relevant Assembly Government official (as shown on appendix 3). A table
summarising the grading, expected response and timescales is attached at appendix 4.
This has been adapted to suit the Wales context from the NPSA National Framework for
Reporting and Learning from Serious Incidents Requiring Investigation.
It is expected that the level of investigation is consistent with the triggers and levels of
RCA investigation published by NPSA (see appendix 5).

Definitions of grading
Grade 0
Concerns currently and commonly referred to as a no surprise and/or where it is initially
unclear whether a serious incident has occurred will be graded 0. Unless further
information is received, Assembly Government will automatically close the incident after 3
days and no further correspondence with the Assembly Government is required. However
organisations will wish to assure themselves of a proportionate and appropriate response
and ensure arrangements are in place to reduce the risk of re-occurrence.
If following initial notification it becomes clear that the issue is an SI then further
information should be sent to the Assembly Government and the grading will be reviewed.
Grade 1
It is expected that a comprehensive investigation (RCA level 2 investigation) will need to
be completed by the organisation within 2 calendar months. In order to close this
incident we will require confirmation that an appropriate SI investigation has been
undertaken; has been reported to an appropriate committee; an action plan developed and
where relevant has identified any actions for wider learning and dissemination. A
closure/update report form should be completed for this purpose as attached at appendix
6. This should also be sent to improvingpatientsafety@wales.gsi.gov.uk. The report will
be reviewed by the relevant Assembly Government officials. They will confirm that they
are content will all actions undertaken and close the incident or seek further
information/action before confirming closure.
If an incident investigation cannot be completed within the timescale agreed the
organisation should complete the closure/update form as far as is possible and seek an
extension to the timescale.
Grade 2
This will follow a similar process to the above. A comprehensive investigation is required,
and in some cases the incident may be referred for independent external review by HIW or
3

other regulatory bodies etc. Grade 2 incidents will be subject to ongoing monitoring by
Assembly Government and final agreement through its Patient Safety Committee that the
incident has been investigated appropriately and thoroughly before closure.
Examples of such incidents could include mental health homicides, maternal deaths,
clusters of similar incidents and never events.

Monitoring and Closure of Incidents

Closure forms and investigation reports (as necessary) for Grade 1 and 2 incidents should
be sent to the IPS mailbox. Meetings will only be held with organisations as necessary.
These will be dependant on the types of incidents, the grading levels, trend and themes of
incidents submitted or if there is concern over the standard or timeliness of the
investigation.

Public Services Ombudsman for Wales and Independent Review

Investigations
In relation to reports that detail the investigation conducted by the Public Services
Ombudsman for Wales (PSOW) and the Independent Review Panel (IRP), into a concern
raised about an NHS Organisation, a copy of the report is also sent to the Welsh Assembly
Government. NHS Organisations are required to inform the PSOW and the IRP how they
have addressed any recommendations outlined in the report and NHS Organisation are
now required to automatically send a copy of any update/action plan to the
Improvingpatientsafety@wales.gsi.gov.uk as well as the PSOW and IRP.

Learning from Incidents

It is key that the outcome of any investigation is used to maximise opportunities for
learning and quality improvement. This should be a key element in our overall attempts to
reduce adverse events and avoidable harm to patients/service users in line with the aims
set out in 1000 Lives Plus programme and individual organisations local priorities. As well
as local learning, organisations are expected to contribute to the wider opportunities for
shared learning. This should be identified when completing the incident closure form.
Issues and learning arising from incidents and complaints will be considered at the
Assembly Government Patient Safety Committee in order to determine any action
required, particularly at a national level Regular reports will also be compiled for the
Director General/Chief Executive NHS Wales and the executive team to help inform policy
development and priorities.

Appendix 1
FORM 1
NOTIFICATION OF SERIOUS INCIDENT
TO WELSH ASSEMBLY GOVERNMENT

WAG Reference

Grading

Internal Ref or
Datix No.

Date reported
to Risk
Management

Organisation
Reporters Name,
Designation and
contact details

Name:
Job title:
Contact details:
E- mail:

Date of making this

report
When did the
incident occur?

Date:

Time (24 hours):

Where did the

incident occur,
including site and
speciality where
relevant?

Local Authority
Area

Who did it affect

and how many?
(personal details
should not be
included)

Age of
patient(s) if
known

Brief description of
what happened

Brief description of
immediate action
taken

Media interest
(actual or potential)
Has this SI been
reported to the
NPSA?
What other external
agencies have
been informed
about this incident?
Any other relevant
information

Chief Executive /
Executive Sign off

Signature:
Print Name:
Title:
Date:

For WAG use

only:

Appendix 2
FORM 2

NOTIFICATION OF NO SURPRISE / SENSITIVE ISSUE

TO WELSH ASSEMBLY GOVERNMENT

WAG Reference

Grading

Organisation
Reporters Name,
Designation and
contact details

Name:
Job title:
Contact details:
E- mail:

Date of making this

report

Brief description of
issue

Brief description of
any action and
media handling

Any other relevant

information

Chief Executive /
Executive Sign off

Signature:

Print Name:
Title:
Date:

Appendix 3

WAG Officials Contact Details

The contact details for the following organisations are:Abertawe Bro Morgannwg University HB
Aneurin Bevan HB
Cardiff & Vale University HB
Cwm Taf HB
Public Health Wales NHS Trust
Velindre NHS Trust

Marion Andrews-Evans
Jenny Sanger
Natalie Harris
Ann-Marie Carpanini
Taryn Ramsay
Sarah Wiltshire

01495 761434
01495 761414
01267 225278
02920 823218
02920 825113
02920 801147

marion.aevans@wales.gsi.gov.uk
jenny.sanger@wales.gsi.gov.uk
natalie.harris@wales.gsi.gov.uk
annm.carpanini@wales.gsi.gov.uk
taryn.ramsay@wales.gsi.gov.uk
sarah.wiltshire@wales.gsi.gov.uk

The contact details for the following organisations are:Betsi Cadwaladr University HB
Hywel Dda HB
Powys Teaching HB
Welsh Ambulance Services NHS Trust

Andrea Hughes
Clare Reece-Archer
Teresa Bridge
John Barnes
Carol Clarke

01352 706951
01352 706956
02920 826797
02920 825857
02920 823825

andrea.hughes2@wales.gsi.gov.uk
clare.reece-archer@wales.gsi.gov.uk
teresa.bridge@wales.gsi.gov.uk
john.barnes@wales.gsi.gov.uk
carol.clarke@wales.gsi.gov.uk

Grade 2

Grade 1

Grade 0

Appendix 4 Grading of serious incidents

Action required:
Notification only for no surprises e.g media coverage of an issue, temporary capacity issues, or if it is unclear if
a serious incident has occurred at this stage.
The organisation must update the Improving Patient Safety Team (IPST) with further information within three
working days of a grade 0 incident being notified.
If within three working days it is found not to be a serious incident, it will be closed by WAG. Should any further
issues arise the HB/Trust should send a further updated report to IPST.
A CAMHS admission to an adult ward should always be notified. This will be graded according to the details of
each individual case
If a serious incident has occurred it will be regraded as a grade 1 or 2.
Examples of cases:
Monitoring required:
Action required:
The HB or Trust will
IPST will close the incident when Unexpected/unexplained death,
investigate the case and
including primary care
it is satisfied that:
report to the IPST findings,
o the investigation,
Mental health attempted suicides as
recommendations,
recommendations and
inpatients
associated action plans and
action plan is satisfactory
Mental Health deaths in the
learning.
and lessons have been
community
HBs and Trusts are
learnt and shared, and
HCAI outbreaks resulting in the death
responsible for informing
o local monitoring
or harm to patients
IPST of any further issues
arrangements are in place
Patient fall resulting in harm/death
that may arise during the
and working efficiently.
Ambulance delays resulting in
course of the investigation
harm/death to patient
e.g. media attention
Data loss and information security
Grade 3 or above hospital acquired
pressure ulcer develops
IRMER reportable incidents
Misidentification/ delay in diagnosis /
treatment or misdiagnosis resulting in
harm / death
Serious medication, blood or device
error
Comprehensive
Investigation
Root Cause Analysis (RCA)
required Level 2
Investigation)
Action required:
Case will be monitored by the
WAG.
They will review findings,
recommendations and
associated action plans and
learning.

Timescales: Up to 2 months from

the date the incident is notified to
the IPST. Extensions will be agreed
on an individual case by case basis.

Comprehensive
Investigation
(RCA level 2 investigation)
(as above) or Independent
Investigation (RCA level 3
Investigation)

Timescales: For internal

investigations timescales as above.
For Independent Investigations 6
months for completion of the
investigation. Extensions will be
agreed on an individual case by
case basis.

Monitoring required:
Incidents involving an
independent investigation or
review or those considered high
risk will continue to be monitored
by WAG officials until evidence is
provided that each action point
has been implemented and there
is evidence of learning
Incidents involving adult or child
abuse are referred to local
safeguarding arrangements

Example of cases:
Maternal deaths
Inpatient suicides (including following
absconsion)
Homicides following contact with
mental health services
Never Events
Safeguarding serious harm or death
following allegations of abuse or
neglectful behaviours (including sexual
abuse)
Some incidents listed in grade 1 above
may be graded 2 depending on the
severity, numbers affected, similar
previous incidents etc

Appendix 5

Root Cause Analysis Investigation Report

National Patient Safety Agency
RCA Investigation Report Template - Guidance
The following headings are designed to improve the recording of information currently considered good
practice for investigation reports. These headings will be evaluated over time to confirm or challenge that
understanding.
PLEASE READ - Instruction for use of this RCA Report Template
1. Determine the level of investigation to be undertaken
Refer to the NPSAs Three Levels of investigation (Level 1 = Concise; Level 2 = Comprehensive; Level
3 = Independent), to the NPSASs Triggers for Investigation, and to your own organisational policy and
terms of reference.
2. Delete all ROWS not required for the level of investigation being undertaken
The investigation level numbers in the middle column provide a guide to which rows are needed for
which level of investigation. (i.e. for a Level 1 - Concise investigation you only need rows which have the
number 1 in the Level column)
3. Write your investigation report in the right hand column
Delete examples (in green), and refer to summary guidance in the left hand column as you go. For
detailed guidance refer to the NPSAs Guide to RCA investigation report writing.
If an investigation produces no information against a heading, add an explanation on why this is the
case.
If issues arise which require a new heading this can be added as a new row
4. On completion, delete the guidance to produce your final report
Delete all guidance both here and in the template below (i.e. all green and red type, all green
coloured rows and all green coloured columns)
Realign the remaining table containing your own report, so that it fits the whole page.
Save the document with the chosen file name for each individual investigation report.

Quick reference guide

Cover page

Level

Type your investigation report in this column

2+3

Organisation name and / or logo

Title or Brief outline of incident
Incident date
Incident number
Author(s)
Report date
Page numbers
Document version
Computer File Path

Contents page

2+3

CONTENTS

Executive summary

2+3

EXECUTIVE SUMMARY

2+3

Brief Incident description

Incident date:
Incident type:
Healthcare specialty:
Actual effect on patient and/or service:
Actual severity of the incident:

A one page summary of the main report

presented succinctly under the following
headings:-

2+3
2+3
2+3
2+3
2+3
2+3

Level of investigation conducted

2+3

Involvement and support of the patient and/or

relatives

2+3

Detection of Incident

10

2+3

Care and Service Delivery Problems

2+3

Contributory Factors

2+3

Root Causes

2+3

Lessons Learned

2+3

Recommendations

2+3

Arrangements for Sharing Learning

Main Report

1, 2 +3

MAIN REPORT

Incident description and

consequences

1, 2 +3

Incident description and consequences

Example only (please delete and add your own findings)

Concise incident description

A lady with asthma sustained brain damage following IV

administration of a drug to which she was known to be allergic.

Incident date

1, 2 +3

Incident type

1, 2 +3

Healthcare speciality involved

1, 2 +3

Actual effect on patient and / or service

1, 2 +3

Actual severity of incident

1, 2 +3

Pre-investigation risk
assessment

2+3

Pre-investigation risk assessment

A
Potential Severity
(1-5)

Assess the realistic likelihood and severity

of recurrence, using your organisations
Risk Matrix

Background and context to the

incident

Incident date:
Incident type:
Specialty:
Effect on patient:
Severity level:

B
Likelihood of recurrence
at that severity (1-5)

2+3

Background and context

2+3

Terms of reference

C
Risk Rating
(C = A x B)

A brief description of the service type,

service size, clinical team, care type,
treatment provided etc.

Terms of reference - Outline :

Specific problems to be addressed

Who commissioned the report
Investigation lead and team
Aims, Objectives and Outputs (see
examples opposite)
Scope, boundaries and collaborations
Administration arrangements
(accountability, resources, monitoring)
Timescales

Investigation team

Example only (please amend to build your own aims)

To establish the facts i.e.:- what happened (the effect), to

whom, when, where, how and why (root causes)
To establish whether failings occurred in care or treatment
To look for improvements rather than to apportion blame
To establish how recurrence may be reduced or eliminated
To formulate recommendations and an action plan
To provide a report as a record of the investigation process
To provide a means of sharing learning from the incident
2+3

The investigation team

Names, Roles, Qualifications, Dept.s

Scope and level of investigation

1, 2 +3

Scope and level of investigation

State level of investigation

(NPSA -1.Concise; 2.Compre.; 3.Independent)

Describe the start and end points

List services & orgs involved
NB: for Level 3 Independent Investigations
scope could be included under Terms of
Reference

Investigation type (i.e. Single /

Aggregation / Multi-incident), process,
and methods used

2+3

Investigation type, process and methods used

Gathering information e.g. Interviews

11

Incident Mapping e.g. Tabular timeline

Identifying Care and service delivery
problems e.g. Change analysis
Identifying contributory factors & root
causes e.g. Fishbones
Generating solutions e.g. Barrier
analysis

Involvement and support of

patient and relatives

1, 2 +3

Involvement and support of patient and relatives

e.g. Meetings to discuss questions the

patient anticipates the investigation will
address and to hear their recollection of
events (anonymised in line with the
patient/relative wishes).
e.g. Family liaison person appointed,
information given on sources of
independent support.

Involvement and support

provided for staff involved

2+3

Involvement and support provided for staff involved

2+3

Information and evidence gathered

Refer (anonymously) to involvement of staff

in the investigation, and to formal &
informal support provided to those involved
and not involved in the incident.

Information and evidence

gathered

Example only (please delete and add your own findings)

A summary list of relevant local and

national policy / guidance in place at the
time of the incident, and any other data
sources used:(Include:-Title and date of Guidance,
Policies, Medical records, interview
records, training schedules, staff rotas,
equipment, etc)

Chronology of events

Interviews with the four staff on duty - 01.02.08

Interviews with patient relatives
- 05.02.08
A visit to the location of the incident -14.02.08
The patients clinical records

1, 2 +3

For complex cases any summary timeline

included in the report should be a summary

Detection of incident

Chronology of events
See table below

1, 2 +3

Detection of incident

Note at which point in the patients

treatment the error was identified. e.g.

At risk assessment of new/changed service

At pre-treatment patient assessment
Error recognition pre-care/treatment
Error recognition post-care/treatment
By Machine/System/Environ. change/Alarm
By a Count/Audit/Query/Review
By Change in patients condition

Notable practice

2+3

Points in the incident or investigation

process where care and/or practice had an
important positive impact and may provide
valuable learning opportunities.
(e.g. Exemplar practice, involvement of the
patient, staff openness etc)

Care and service delivery

problems
A themed list of the key problem points.
(Where many problems have been
identified the full list should be included in
the appendix)

Notable practice
Example only (please delete and add your own findings)

Actions taken to inform the patient and relatives of the error in

an open and honest way, and to subsequently involve them in
the RCA process was valued by all and greatly enhanced the
investigation.
1, 2 +3

Care and service delivery problems

Example only (please delete and add your own findings)

Nurses on the short stay ward routinely failed to complete the

section in the patient notes to highlight the existence of known
allergies

12

Contributory factors

1, 2 +3

A list of significant contributory factors

(where many contributory factors are
identified a full list or fishbone diagrams
should be included in the appendix)

Root causes (numbered)

Example only (please delete and add your own findings)

Over years numerous assessments for nutrition, pressure
ulcers, falls risk etc. had been added, causing short stay wards
to see the completion of all documentation as impossible.
1, 2 +3

These are the most fundamental underlying

factors contributing to the incident that can
be addressed. Root causes should be
meaningful, (not sound bites such as
communication failure) and there should be
a clear link, by analysis, between root
CAUSE and EFFECT on the patient.

Lessons learned (numbered)

1. When adding or updating patient assessments and care

plans, risk assessment of the wider implications of their use
should be conducted and acted upon to reduce the risk of
impact on patient safety
1, 2 +3

1. A distinction should be made between essential and desirable

documentation in clinical records
1, 2 +3

Recommendations
Example only (please delete and add your own findings)

1. Ensure allergy records and other priority assessment sheets

are routinely filed prominently for ease of completion
2. Ensure essential assessment criteria are set as mandatory
fields in new electronic record development
1, 2 +3

Arrangements for shared learning

Example only (please delete and add your own findings)

Describe how learning has been or will be

shared with staff and other organisations
(e.g. through bulletins, PSAT/Regional
offices, professional networks, NPSA, etc.)

Distribution list

Lessons learned
Example only (please delete and add your own findings)

referenced) Recommendations should be

directly linked to root causes and lessons
learned, They should be clear but not
detailed (detail belongs in the action plan).
It is generally agreed that key
recommendations should be kept to a
minimum where ever possible.

Arrangements for shared

learning

Root causes
Example only (please delete and add your own findings)

Key safety and practice issues identified

which may not have contributed to this
incident but from which others can learn.

Recommendations (numbered and

Contributory factors

y Share findings with other departments caring for short stay

patients and include them in piloting solutions
y Share findings with patient Safety Action Team to identify
opportunities for sharing outside the organisation
2+3

Distribution list

2+3

Appendices

Describe who (e.g. patients, relatives and

staff involved) will be informed of the
outcome of the investigation and how

Appendices
Include key explanatory documents. e.g.
Tabular timeline, Cause + effect chart,
Acknowledgements to patients, family, staff
or experts etc.

Author:
Job Title:
Date:

13

Chronology (timeline) of events

Date & Time

Event

14

Root Cause Analysis Investigation Report - Concise

Incident description and consequences
Incident date:
Incident type:
Specialty:
Effect on patient:
Severity level:
Scope and level of investigation

Involvement and support of patient and relatives

Detection of incident

Notable practice
.

Care and service delivery problems

Contributory factors

Root causes

Lessons learned

Recommendations

Arrangements for shared learning

Author:
Job Title:
Date:

15

Chronology (timeline) of events

Date & Time

Event

16

Root Cause Analysis Investigation Report - Comprehensive

CONTENTS
EXECUTIVE SUMMARY
Brief Incident description
Incident date:
Incident type:
Healthcare specialty:
Actual effect on patient and/or service:
Actual severity of the incident:
Level of investigation conducted
Involvement and support of the patient and/or relatives
Detection of Incident
Care and Service Delivery Problems
Contributory Factors
Root Causes
Lessons Learned
Recommendations
Arrangements for Sharing Learning

MAIN REPORT
Incident description and consequences
Incident date:
Incident type:
Specialty:
Effect on patient:
Severity level:
Pre-investigation risk assessment
A
Potential Severity
(1-5)

B
Likelihood of recurrence
at that severity (1-5)

Background and context

Terms of reference

The investigation team

Scope and level of investigation

17

C
Risk Rating
(C = A x B)

Investigation type, process and methods used

Involvement and support of patient and relatives

Involvement and support provided for staff involved

Information and evidence gathered

Chronology of events - See table below

Detection of incident

Notable practice
.

Care and service delivery problems

Contributory factors

Root causes

Lessons learned

Recommendations

Arrangements for shared learning

Distribution list

Appendices
Author:
Job Title:
Date:

18

Chronology (timeline) of events

Date & Time

Event

19

Appendix 6
FORM 3
CLOSURE / UPDATE FOLLOWING SERIOUS INCIDENT
TO WELSH ASSEMBLY GOVERNMENT

WAG Reference

Grading

Organisation

Date of
incident

Summary of
incident

Summary of
investigation
findings and
recommendations

Confirmation of
Actions to be
implemented

Timescale

20

Any outstanding
issues

Issues identified for

shared
learning/action

Any additional
information
attached

Yes: [

Disclaimer

I confirm that this incident has been thoroughly investigated and the
findings and recommendations have been agreed by the appropriate
committee and acted upon

No: [

Or
The information provided on this form summarise the action to date and we
request an extension of ____ weeks to complete this investigation.
Signature

Chief Executive/Executive Director

Date

FOR WAG USE

ONLY:
Incident Closed

WAG Officials
sign off

Further
action
required
Yes: [

No: [

Signature:
Date:

21