In broad terms, serious incidents are events in health care where the potential for learning is so great, or the consequences to service users, families and carers, staff organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect service users directly and include incidents which may indirectly impact service user safety or an organisation’s ability to deliver ongoing service.
Serious incidents can be isolated, single events or multiple linked or unlinked events signalling systemic failures within a commissioning or health
system.
The definition below sets out circumstances in which a serious incident must be declared. Every incident must be considered on a case-by-case basis using the description below. Inevitably, there will be borderline cases that rely on the judgement of the people involved.
Serious Incidents, in this context, include:
Section 1: Acts and / or omissions occurring as part of Open Mental Health (OMH) service offers that result in:
i) Unexpected or avoidable death of one or more people. This includes:
- Suicide / self-inflicted death
- Homicide by a person in receipt of mental health care within the recent past
ii) Unexpected or avoidable injury to one or more people that has resulted in serious harm
iii) Unexpected or avoidable injury to one or more people that requires further treatment by a healthcare professional in order to prevent:
- Death
- Serious harm
iv) Actual or alleged abuse; sexual abuse, physical or psychological ill-treatment, or acts of omission which constitute neglect, exploitation, financial or material abuse, discriminative and organisational abuse, self-neglect, domestic abuse, human trafficking and modern day slavery where:
- OMH services did not take appropriate action / intervention to safeguard against such abuse occurring
- Where abuse occurred during the provision of an OMH service offer
v) Significant impact, or the potential for significant impact, to the reputation of the OMH alliance. Examples of which are:
- Financial or material abuse including theft, fraud, scamming, putting pressure on individuals with regard to their financial arrangements, or the misuse or stealing of property, possessions or benefits
- The misappropriation of assets by a staff member or professional associated with Open Mental Health
Section 2: An incident, or series of incidents, that prevents, or threatens to prevent, an organisation’s ability to continue to deliver an acceptable quality of service including, but not limited to, the following:
- Failures in the security, integrity, accuracy or availability of information often described as data loss and / or information governance related issues. e.g. Special Category data loss as a result of a data breach
- Property damage requiring repair (by fire or otherwise)
- Security breach / concern
- Inappropriate enforcement / care under the Mental Health Act (1983) and the Mental Capacity Act (2005) including Mental Capacity Act, Deprivation of Liberty Safeguards (MCA DOLS)
- Systematic failure to provide an acceptable standard of safe care (when in a relevant setting)
- Receipt of a statutory notification expressing concern around an Open Mental Health service offer from an external regulatory body
- Activation of major incident plan / business disaster recovery plan
Section 3: Acts and / or omissions occurring as part of OMH service offers (that include support within a care setting or provision of equipment for service users) that result in:
i) Failure to install functional collapsible shower or curtain rails in any OMH setting providing mental health inpatient care. This involves:
- Failure of collapsible curtain or shower rails to collapse when a service user attempts or completes a suicide
- Failure to install collapsible rails and a service user attempts or completes a suicide using non-collapsible rails
ii) Falls from poorly restricted windows in any OMH setting providing care. This applies to:
- Windows ‘within reach’ of service users; this means windows (including the window sills) that are within reach of someone standing at floor level and that can be exited/fallen from without needing to move furniture or use tools to climb out of the window
- Windows located in facilities/areas where healthcare is provided and that service users can and do access
- Where service users deliberately or accidentally fall from a window where a fitted restrictor is damaged or disabled, but not where a service user deliberately disables a restrictor or breaks the window immediately before they fall
- Where service users can deliberately overcome a window restrictor using their hands or commonly available flat-bladed instruments as well as the ‘key’ provided
iii) Chest or neck entrapment in bed rails. This applies to all OMH settings providing care including service users’ own homes where equipment for their use has been provided by OMH services
- Entrapment of a service user’s chest or neck between bedrails or in the bedframe or mattress, where the bedrail dimensions or the combined bedrail, bedframe and mattress dimensions do not comply with Medicines and Healthcare products Regulatory Agency (MHRA) guidance