TRUST POLICY AND PROCEDURES FOR REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURENCES. Status: APPROVED. Version Date Author Reason

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1 TRUST POLICY AND PROCEDURES FOR REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURENCES Ref Number: Version: Status: Author: POL-RKM/2016/043 V1 APPROVED Health and Safety Team Version / Amendment History Version Date Author Reason 1 September 2016 Health and Safety Team New Policy Intended Recipients: All staff Training & Dissemination: Health & Safety Training - Reporting, Recording & Investigating Accident/Incidents Policy disseminated via the Trust Intranet To be read in conjunction with: Trust Health and Safety Policy Trust Policy and Procedures for Incident Reporting, Analysing, Investigating and Learning In consultation with and Date: Operational Health and Safety Steering Group Strategic Health and Safety Committee EIRA stage One Completed Yes Stage Two Completed No Procedural Documentation Review Group Assurance and Date Strategic Health and Safety Committee Management Executive 13/09/2016 Approving Body and Date Approved Strategic Health and Safety Committee 13/09/2016 Page 1 of 22

2 Date of Issue September 2016 Review Date and Frequency September 2019 (3 yearly) Contact for Review Health and Safety Manager Executive Lead Signature Approving Executive Signature Director of Workforce and Corporate Development Chief Executive Page 2 of 22

3 Contents 1 Introduction Purpose and Outcomes Definitions Used Key Responsibilities/Duties Senior Managers/Executive Directors Line Managers Employees Health and Safety Team Reporting Process Death Specified injuries Over-seven-day injuries Reportable diseases Dangerous Occurrences Investigating post events Keeping records Staff Support Following an Incident Training Further Information Monitoring Compliance and Effectiveness References Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Good Practice Checklist for Managers Examples to establish whether RIDDOR applies Accident Investigation Report Letter Accident and Incident Investigation Record (Non-clinical) RIDDOR Management Audit Tool Incident Reporting Procedure Page 3 of 22

4 TRUST POLICY AND PROCEDURES FOR REPORTING OF INJURIES, DISEASES AND DANGEROUS OCCURRENCES 1 Introduction Derby Teaching Hospitals NHS foundation Trust acknowledges it has statutory responsibility as an employer to report specified incidents in accordance with the Health & Safety at work etc. Act 1974 and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR). The Trust aims to ensure all reportable cases of work related injuries, diseases and dangerous occurrences are reported to the Health & Safety Executive in the approved manner and within legally defined timescales. 2 Purpose and Outcomes This policy is intended to provide managers and staff with guidance on RIDDOR reportable incidents. It contains details of the types of incidents that are RIDDOR reportable and the methods in which they should be reported. 3 Definitions Used An incident includes: An accident: an event that results in injury or ill health Near miss: an event that, while not causing harm, has the potential to cause injury or ill health. (In this guidance, the term near miss will be taken to include dangerous occurrences); Undesired circumstance: a set of conditions or circumstances that have the potential to cause injury or ill health, e.g. untrained nurses handling heavy patients. A reportable specified injury, as defined by the HSE, includes: Fracture other than fingers, thumbs or toes Amputation Any injury likely to lead to permanent loss of sight or reduction in sight Any crush injury to the head or torso causing damage to the brain or internal organs Serious burns (including scalding) which: Covers more than 10% of the body Causes significant damage to the eyes, respiratory system or other vital organs Any scalping requiring hospital treatment Any loss of consciousness caused by head injury or asphyxia Any other injury arising from working in an enclosed space which: o Leads to hypothermia or heat-induced illness o Requires resuscitation or admittance to hospital for more than 24 hours Page 4 of 22

5 A reportable dangerous occurrence includes: collapse, overturning or failure of load-bearing parts of lifts and lifting equipment; explosion, collapse or bursting of any closed vessel or associated pipe work; plant or equipment coming into contact with overhead power lines; electrical short circuit or overload causing fire or explosion; any unintentional explosion, misfire, failure of demolition to cause the intended collapse, projection of material beyond a site boundary, injury caused by an explosion; accidental release of a biological agent likely to cause severe human illness; collapse or partial collapse of a scaffold over five metres high, or erected near water where there could be a risk of drowning after a fall; a dangerous substance A reportable disease includes: carpal tunnel syndrome; severe cramp of the hand or forearm; occupational dermatitis; hand-arm vibration syndrome; occupational asthma; tendonitis or tenosynovitis of the hand or forearm; any occupational cancer; any disease attributed to an occupational exposure to a biological agent. 4 Key Responsibilities/Duties 4.1 Senior Managers/Executive Directors Ensure that they and their employees are familiar with this and associated policies. Ensure that all notifications of RIDDOR reportable incidents have formally been reported to the Health & Safety Executive. 4.2 Line Managers Ensure that they and their employees are familiar with this and associated policies. Investigate all notifications on injuries, diseases and dangerous occurrences to determine whether they require formal reporting to the HSE. Notify the Health and Safety Team of all reportable incidents. Inform the senior manager/executive on call of any work-related deaths. 4.3 Employees Ensure that they are familiar with this and associated policies. Advise their manager immediately of any reportable injury, occupational disease or dangerous occurrence that has occurred Ensure all incidents, no matter how trivial, are formally recorded Page 5 of 22

6 Ensure all equipment is used correctly and safely in accordance with instructions and training Assist and support in the investigation of incidents. 4.4 Health and Safety Team Assist and support in the investigation of incidents. Receive notification of and scrutinise incidents against RIDDOR reportable criteria. Inform the Head of Patient Safety of possible patient related RIDDOR reportable incidents Report all notifications of RIDDOR reportable incidents to the Health & Safety Executive. 5 Reporting Requirements Under RIDDOR work-related incidents, diseases and dangerous occurrences must be reported to the HSE. This requirement covers all work activities but not all incidents. All incidents must be reported to the relevant manager, details of the incident must be reported on DATIX (IR1) and first aid/emergency treatment given as necessary. For all RIDDOR reportable incidents these must be identified on the DATIX IR1 form. The following incidents are reportable if they arise out of or in connection with work: Incidents which result in an employee or a self-employed person dying, suffering a specified injury, or being absent from work or unable to do their normal duties for more than seven days. Incidents which result in a person not at work suffering an injury and being taken to a hospital, or if the accident happens at a hospital, suffering a specified injury. An employee or self-employed person suffering one of the specified workrelated diseases. One of the specified dangerous occurrences - these do not necessarily result in injury but have the potential to do significant harm. See Appendix 2 for example incidents to establish whether RIDDOR applies. Where an incident has been identified as RIDDOR reportable the health and safety team will receive notification and will report RIDDOR reportable incidents to the Health & Safety Executive. 5.1 Death The Trust has a duty to report the death of any person, whether or not they are at work if it is caused by an accident arising out of or in connection with work. In the event of a work-related accident resulting in a death, your line manager and senior manager/executive on call (helpdesk) must be informed immediately, the incident recorded on DATIX (IR1) and the health and safety team informed at the earliest opportunity. Page 6 of 22

7 Once notified the health and safety team will submit an online form to the Health & Safety Executive. The report must be made within 10 days of the incident. Should the health and safety team not be able to be contacted within 10 days, the senior manager/executive on call must notify the HSE Incident Contact Centre by telephone on The Centre operator will ask for brief details about the injured person, the accident, and the person making the report. 5.2 Specified injuries The Trust has a duty to report all incidents which result in any person, whether or not they are at work suffering from a specified injury, if it is caused by an accident arising out of or in connection with work. In the event of a work-related accident resulting in a specified injury, your line manager and senior manager/executive on call must be informed immediately, the incident recorded on DATIX (IR1) and the health and safety team informed at the earliest opportunity. Once notified the health and safety team will submit an online form to the Health & Safety Executive. The report must be made within 10 days of the incident. Should the health and safety team not be contacted within 10 days, the senior manager/executive must notify the HSE Incident Contact Centre by telephone on The Centre operator will ask for brief details about the injured person, the accident, and the person making the report. 5.3 Over-seven-day injuries The Trust has a duty to report injuries that lead to an employee being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of an occupational accident or injury (not counting the day of the accident but including weekends and rest days). In the event of a work-related accident resulting in an over seven day incident your line manager must be informed immediately, the incident recorded on DATIX (IR1) and the health and safety team informed at the earliest opportunity. Once notified the health and safety team will submit an online form to the Health & Safety Executive. The report must be made within 15 days of the incident. 5.4 Reportable diseases The Trust has a duty to report where a Registered Medical Practitioner tells them in writing that one of their employees is suffering from a reportable disease, infection or ill-health, and the employee undertakes work linked with that condition. If you receive written diagnosis that you or an employee, is suffering from a reportable disease inform the health and safety team at the earliest opportunity. Once notified the health and safety team will submit an online form to the Health & Safety Executive. For the purposes of RIDDOR, an infection is the entry and multiplication of an infectious agent in the body, causing a damaging reaction to the tissue. The infection and damage caused may give clinical signs and symptoms of disease, Page 7 of 22

8 or may be subclinical or asymptomatic. Colonisation (the presence and multiplication of infectious agents in or on the body, without a damaging reaction in the tissue) is not the same as infection and is not reportable as a disease. Infections that could have been acquired as easily in the community as in work are not reportable, unless the infection was definitely acquired at work. Stress is not reportable as an occupational injury, even when accompanied by a medical certificate stating it is work-related, because it does not result from a single definable accident. 5.5 Dangerous Occurrences The Trust has a duty to report several types of dangerous occurrence where the incident has the potential to cause injury or death. In the event of a work-related dangerous occurrence, your line manager must be informed immediately, the incident recorded on DATIX (IR1) and the health and safety team informed at the earliest opportunity. Once notified the health and safety team will submit an online form to the Health & Safety Executive. 5.6 Investigating post events Following an incident reportable under RIDDOR it is important to ensure that a robust internal investigation is conducted and documented on the incident details. This may include updating the risk assessment, control measures and what actions have been taken to prevent this from happening again. This is a legal requirement under the Management of Health and Safety at Work Regulations 1999 and will provide documented evidence if the HSE contact the organisation following a RIDDOR report. Once the health and safety team have been notified of a RIDDOR incident the relevant manager will be sent an Accident Investigation Record Form to complete Appendices 3 and Keeping records A record of all reportable injury, disease or dangerous occurrences must kept for three years from the date of being reported; including the date and method of reporting; the date, time and place of the event; personal details of those involved, and a brief description of the nature of the event or disease. If the person who has had the accident was under the age of eighteen then the accident records have to be kept until they are 21. Incident report forms are recorded electronically on a central database. The Trust must keep a record of incidents if the worker has been incapacitated for more than three consecutive days and must retain a copy of the incident form completed by the member of staff under the Social Security (Claims and Payments) Regulations Page 8 of 22

9 5.8 Staff Support Following an Incident In the event of an incident, staff must report it to their line manager immediately as the first point of contact before involving other agencies, e.g. Occupational Health Service, the Health and Safety Team or the Police. This excludes dialling 999 for emergency police response in on-going emergency (or other appropriate) situations. Following an incident, managers should ensure that staff are given the opportunity to discuss the incident in a debriefing session and receive assistance in the preparation of appropriate Incident reports. Staff should also be given the opportunity to contact supportive agencies. The Occupational Health Service can fulfil this role and arrange referral to external agencies if necessary, including an independent counsellor. Arrangements for time off to attend supportive agencies should be made in consultation with line managers. Staff can also obtain assistance and advice from their Union-appointed Health and Safety Representative. Staff should be aware of the possibility that complaints against their own conduct may arise after an incident. Support and advice from both management and staff organisations will be available in case a complaint about the conduct of a staff member is made when dealing with an incident. 5.9 Training Reporting, recording & investigating accident/incidents training is a non-mandatory, essential to role course delivered by the health and safety team for managers to understand and guide employees in accident recording, reporting and investigation. Contact the health and safety team for course availability dhft.healthandsafety@nhs.net 5.10 Further Information HSE guidance This is a short list of some of the guidance available from HSE, for more information visit HSE s website on RIDDOR in health and social care Reporting injuries, diseases and dangerous occurrences in health and social care: Guidance for employers Health Services Information Sheet No 1 (revised) Information for doctors relating to RIDDOR HSE32 Measuring health and safety performance A guide Page 9 of 22

10 Investigating Accidents and Incidents HSG245 Other guidance and links NHS Employers Health and Safety Essential Guides TUC Safety Representatives Resources 6 Monitoring Compliance and Effectiveness The Health and Safety Team will review any legislative changes and all RIDDOR incidents and produce incident statistics and summaries for the Operational Health and Safety Steering Group and Strategic Health and Safety Committee. The RIDDOR Management Audit Tool see Appendix 6 is to be used by directors, managers with health and safety responsibilities and safety representatives to assess levels of compliance with health and safety legislation. The key findings will be monitored in a composite Annual Health and Safety report. Monitoring Requirement : Report Prepared by: Monitoring Report presented to: Management of Health and Safety at Work Regulations 1999, Regulation 5 Health and Safety Team Strategic Health and Safety Committee Management Executive Trust Board Frequency Report of Annually 7 References Health and Safety at Work etc Act Management of Health and Safety at Work Regulations Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Reporting injuries, diseases and dangerous occurrences in health and social care - Guidance for employers (HSE fact sheet) Page 10 of 22

11 Good Practice Checklist for Managers APPENDIX 1 Are your staff: 1. Briefed about incident reporting? 2. Given all relevant information available about RIDDOR? 3. Aware of the procedures for reporting of RIDDOR reportable incidents? Are they: 4. Aware of the importance of recording incidents? 5. Aware of the need to inform managers of incidents? 6. Aware of how to obtain support and advice from management in and outside normal working hours? Do they: 7. Appreciate their responsibilities for recording and reporting of incidents? 8. Understand the provisions for staff support by the Trust and the mechanism to report incidents? 9. Appreciate the requirements for reporting and recording incidents in relation to RIDDOR? Page 11 of 22

12 Examples to establish whether RIDDOR applies APPENDIX 2 The fact that there is an accident at work premises does not, in itself, mean that the accident is work-related. An accident is work related if any of the following played a significant role: The way the work was carried out If any machinery, substance, plant or equipment was used for the work The condition of the site or premises where the accident occurred. In relation to RIDDOR, an accident is a separate, identifiable, unintended incident which causes physical injury. This specifically includes acts of non-consensual violence to people at work. Accidents which arise solely from the medical condition of the injured person are not reportable. Injuries themselves (e.g. feeling a sharp twinge) are not accidents. There must be an identifiable, external event that causes the injury. Cumulative exposures to hazards, which eventually cause injury (e.g., repetitive lifting), are not classed as accidents under RIDDOR. Example Reportable Explanation YES NO Confused patient falls from a window on an upper floor and is badly injured Member of public climbs onto scaffolding erected in hospital premises, falls and dies The window was not fitted with restrictors The scaffolding has been erected in connection with and arising out of work. Visitor entering hospital slips and falls in corridor and breaks arm (no trip hazards, spillages, wet floor etc.) There are no failures or defects identified which contributed to the fall. Visitor to DHFT premises trips over a vacuum cleaner cable, suffers a fracture and is taken to hospital (if not already in hospital premises) Injury is work related (for example, tripped over vacuum cleaner cable where no warning signs are displayed) Page 12 of 22

13 A frail elderly women falls and breaks her leg in a outpatient dept. There are no obstructions or defects in the dept which contributed to her fall. Example Reportable Explanation YES NO A doctor is injured by a sharp containing patients blood. A hospital patient falls out of bed and is injured. There was a detailed assessment in the care plan that identified that fall protection was not required. Not reportable as the patient is not known to have any infection Not reportable as there are no failures or defects identified. A hospital patient falls out of bed and is injured. The assessment within the care plan had identified the need for bedrails but they, or other preventative measures, had not been provided A hospital patient falls from bed and receives a significant burn from a radiator Reportable as failure to provide preventative measures. Radiator did not have protective covers fitted. Reportable classed as a specified injury Member of staff is involved in a car accident travelling from one base to another Not reportable under RIDDOR. Reported under the Road Traffic Act 1988 Example Reportable Explanation YES NO Employee injures hand at work and fractures a finger but does not have more than 7 days away from work Fractures to fingers, thumbs or toes are not reportable Page 13 of 22

14 Employee falls down a pothole in the hospital car park and sustains a fracture A patient hoist fails, due to overload Reportable classed as a specified injury / over seven day injury defect in car park caused accident Reportable under dangerous occurrences Patient falls out of bed, fractures hip and later dies. Patient assessment had not highlighted any need for bed rails etc. Contractor working on Trust premises is injured whilst using his own machinery There are no failures or defects identified which contributed to their fall. Not reportable by the Trust. The contractor s employer is responsible for reporting under RIDDOR. As good practice incident should be logged on incident reporting system. Example Reportable Explanation YES NO Healthcare worker contracts dermatitis due to contact with latex gloves Nurse contracts active pulmonary TB after nursing a patient with the condition Occupational dermatitis listed under Reportable Diseases in the RIDDOR regulations. Registered medical practitioner has confirmed that the disease is attributable or contributed to by the work activity. TB listed under Reportable Diseases in the RIDDOR regulations. It is clear that the disease is attributable to the work activity. Receptionist contracts chicken pox. Patients in the areas where he/she has worked have chicken pox. Infection / disease cannot be reliably attributed to the workplace as it might just as easily have occurred at home or in the community. Page 14 of 22

15 HCA is off work for two weeks with flu. Patients on the ward have flu. Infection / disease cannot be reliably attributed to the workplace as it might just as easily have occurred at home or in the community. Example Reportable Explanation YES NO Member of staff has an existing back problem which is well managed. When moving a patient using appropriate equipment, back injury is aggravated and results in member of staff being off work for more than seven days. Injuries themselves (e.g. feeling a sharp twinge) are not accidents. There must be an identifiable, external event that causes the injury. Cumulative exposures to hazards, which eventually cause injury (e.g. repetitive lifting), are not classed as accidents under RIDDOR Reference: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) Health and Safety Executive Health Services Information Sheet RIDDOR Guidance for Employers Page 15 of 22

16 APPENDIX 4 Line Manager Health and Safety Team Royal Derby Hospital Uttoxeter Road Derby DE22 3NE Date: Ref: Dear Line Manager, Re: INVESTIGATION for: Incident number: Date of incident: Nature of Incident: Return to Health and Safety Team by: As manager of your department, would you please complete an investigation that gives the root cause including any risk assessments for the attached incident and identify the measures needed to avoid future incidents of a similar nature. As part of the investigation, a description of the incident by the injured person and/or witness (es) is requested to enable a more detailed description than provided on the incident form. Wherever possible these statements should be written (by hand or typed) by the people named in the incidents using their own wording. This should include an account of the facts as they recall them, and may include any issues they consider relevant to the cause of the incident. It does not affect any rights to legal advice or compensation and they should be advised of this aspect. All the information collected in this post-injury investigation is subject to disclosure and therefore would be provided on request by a solicitor should any compensation be sought at any time. I look forward to receiving your report by the above date. Yours sincerely, Health and Safety Team Tel: dhft.healthandsafety@nhs.net Page 16 of 22

17 Accident and Incident Investigation Record (Non-clinical) APPENDIX 5 Date of Incident/accident: XX/XX/XXXX Incident Report Ref no: Brief description of accident/incident: Location of accident/incident: (please include address & full postcode) Location of accident/incident on site: Investigated by (print name): Date of Investigation: XX/XX/XXXX Page 17 of 22

18 Name & contact details of witness(es) to accident/incident: Witness to briefly state what happened (witness statement): Immediate cause(s): Underlying cause(s): Page 18 of 22

19 Root Cause(s): Was a risk assessment in force? (Please tick box) Yes No If yes, attach a copy of the risk assessment. Date form completed: XX/XX/XXXX Signature: Print name: Page 19 of 22

20 RIDDOR Management Audit Tool APPENDIX 6 Criteria Evidence Legal References Observations The organisation has an incident reporting procedure, which sets out the requirements of accident and incident reporting under RIDDOR. Policy and procedures Management of Health and Safety at Work Regulations 1999, Regulations 5 The procedure identifies the roles and responsibilities of individuals, for example: who identifies whether an incident is RIDDOR reportable who is responsible for reporting reportable incidents to HSE. The procedure identifies the differences of incident reporting for staff, patients and members of the public. Policy and procedures Policy and procedures Management of Health and Safety at Work Regulations 1999, Regulations 5 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, Regulations 3, 4, 5, and 6 Management of Health and Safety at Work Regulations 1999, Regulations 5 and 10 The organisation communicates procedures on RIDDOR clearly to staff. Staff are encouraged to report near misses. Policy and procedures Flow diagrams Policy and procedures Staff surveys Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, Regulations 3, 4, 5, & 6 Management of Health and Safety at Work Regulations 1999, Regulation 5 and 10 Page 20 of 22

21 Staff surveys include questions on under reporting of incidents. Staff surveys Focus groups The organisation has systems in place to ensure appropriate records are kept. Policy and procedures Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995, Regulation 7 The organisation shares relevant RIDDOR information with safety representatives as required by the under the Safety Representatives and Safety Committees Regulations Committee meetings and minutes Safety Representatives and Safety Committees Regulations 1977 Page 21 of 22

22 Incident Reporting Procedure NB: Full sized laminated posters available from the health and safety team. APPENDIX 7 Page 22 of 22