Discussion Assurance Approval Regulatory requirement Mark relevant box with X

Report to: Board of Directors Date of Meeting: 26 th July 2017 Report Title: Health and Safety Annual Report Status: For information Discussion Assurance Approval Regulatory requirement Mark relevant box with X X X X Prepared by: Carol Woolgar, Resilience and Governance Manager Executive Stacey Hunter, Chief Operating Officer Sponsor (presenting): Appendices (list if applicable): Purpose of the Report Health and safety (H&S) law places specific duties on organisations. Employers and Directors can be held personally liable when these duties are breached, and members of the board have both collective and individual responsibility for health and safety. The Board are reminded that their obligations under H&S require it to be considered within the decision making framework of the Board. The attached H&S Annual report details the organisation s activity relating to, and governance arrangements for, all aspects of H&S from 1st April 2016 to 31 st March 2017. Key points for information The governance structure for H&S, which has also scrutinised the production of this report Reported incidents during the period covered by the report, any noted trends and adequacy of mitigating action Recommendation Consider and approve the Health and Safety annual report Page 1 of 19

Page 2 of 19 HEALTH AND SAFETY ANNUAL REPORT 2016-2017

Executive Summary Health and Safety (H&S) is recognised by Airedale NHS Foundation Trust (ANHSFT) to be fundamental in the delivery of safe services for staff, patients, carers and visitors. Progress to ensure that the organisation meets the requirements for health and safety legislation was consistent throughout 2016-2017. Going forward, the annual plan for 2017-2018 will continue to progress management of health and safety across the Trust, with particular focus on Assessing, monitoring and providing assurance that all premises are fit-forpurpose Ensuring the analysis of trends and themes in adverse event reporting continues, and any resulting lessons are identified and implemented. Validating the results of, and addressing issues identified by, the Selfinspection audit and gap analysis against the NHS Staff Council Workplace Health and Safety Standards Raising the level of mandatory training attendance across all aspects of H&S Monitoring policy compliance and addressing any resulting issues related to health and safety. 1. Background It is a requirement that the Trust Board of Directors receive an annual Health and Safety (H&S) report covering the Trust s H&S activities. For the purpose of this report the following statutory requirements of the Health and Safety at Work Act 1974 (HASAWA) are referred to; Section 2 - Duties of employers to employees; Section 3 - Duties to protect people who are not its employees from being exposed to the risks of its activities (e.g. patients, members of the public); Section 4 - Duties as a landlord by being in control of premises; The Management of Health and Safety at Work Regulations 1999 (HASAWR) extend the provisions of the HASAWA and in particular the requirement to undertake suitable and sufficient risk assessments and provide adequate training and supervision. Further regulations cover specific aspects of H&S for example the Control of Substances Hazardous to Health (COSHH) Regulations. Whilst not included under the HASAWA fire safety remains an essential requirement to ensure the H&S of people present on our sites. The Regulatory Reform (Fire Safety) Order 2005 (RRO) became law in 2006 and covers all fire legislation, alongside the RRO are the Firecode suite of documents and the building regulations. Together these documents form the basis of all fire safety on site, including fire safety training and emergency evacuation Radiation protection is carried out in conjunction with Radiation Physics Advisors from Bradford Teaching Hospitals Foundation Trust, monitored by the Ionising and Non-Ionising Radiation Protection Group meetings with assurance presented to the Joint Health, Safety and Resilience Committee via an annual report. Page 3 of 19

2. Introduction The Joint Health, Safety and Resilience Committee (JHSRC) has delegated responsibility from the Board for all issues relating to H&S and oversees the overall H&S strategy to ensure it meets the standards required by the Health and Safety Executive and statutory regulation. The purpose of this report is to inform the Trust Board of Directors of activity relating to all aspects of H&S from 1 st April 2016 to 31 st March 2017. 3. Key Legislation for 2016-2017 No new pieces of H&S legislation relevant to ANHSFT came into force during this period. Revised guidance was issued on the following piece of legislation during this period. The Manual Handling lead carried out gap analysis to the existing arrangements at the Trust and the results were submitted to the H&S Operational Group (H&S Op Gp) for assurance. L23 - Manual Handling Operations Regulations 1992 Guidance on Regulations (fourth edition) 4. Health and Safety Requirements The HASAWA and the HASAWR require that ANHSFT has a system in place to proactively manage and control risks. In order to meet these legal requirements ANHSFT manages its risks based on the Health and Safety Executive model published in Successful Health and Safety Management (HSG65) which is one based on the plan-do-check-act approach (see figure 1) Figure 1. The Current HSG65 H&S Management Approach Page 4 of 19

The following provides an overview of activity at the Trust referenced to HSG65 requirements Table 1 ANHSFT Evidence for HSG65 Compliance HSG 65 ANHSFT Evidence monitored by the JHSRC Requirement Plan determine your policy / plan for implementation The following policies were updated during the period Control of Artificial Optical Radiation Policy Dignity at Work Policy Fire Safety Policy Infection Prevention and Control Policy Manual Handling Policy Medical Devices Policy Medical Gas Policy Mobile Phone Policy Pest Control Policy Slip, Trip Fall Policy for Staff, Visitors and Others Waste Policy The following polices remained in date for the period and have not required amendment Alcohol and Drugs at Work Policy Breastfeeding and Returning to Work Policy Contamination Injuries Prevention and Management Policy Control of Contractors Policy COSHH Policy Display Screen Equipment Policy Estates Policy Health and Safety Policy Induction Policy Ionising Radiation Protection Policy Latex Policy Mandatory Training Policy Mental Health, Wellbeing and Resilience Policy Prevention And Management Of Slips, Trips And Falls Involving Patients (Children And Adults) Policy Security, Violence and Aggression Policy Smoke Free Policy Training and Development Policy Uniform and Workwear Policy and Code of Appearance Policy Water Policy Work Experience Policy Page 5 of 19

HSG 65 Requirement Do - Organise for H&S Implement your plan ANHSFT Evidence monitored by the JHSRC The JHSRC provides assurance to the Executive Assurance Group and Trust Board of Directors. Its work is supported by the H&S Op Gp and specific sub-groups for slips, trips and falls, manual handling, Ionising Radiation Protection and Non-Ionising Radiation Protection, COSHH and contamination injuries. A subgroup covering violence and aggression was set-up during 2016-17. Director of Operations is responsible for H&S and chairs the JHSRC Assistant Director of Estates and Facilities is delegated chair of the H&S Op Gp and assumes responsibility for the local security management specialist services (LSMS) and Fire. A Fire Safety Manager is in place The Resilience and Governance Manager is designated as the competent person and holds the NEBOSH diploma. Staff side health and safety representatives are involved in all aspects of health and safety decision making, this includes membership on all health and safety groups and committees. Mandatory and local training are provided for the following Quality & Safety; Manual handling; Infection prevention; Conflict resolution; Incident reporting; and Fire Response team; Page 6 of 19

HSG 65 Requirement Do Profile risks ANHSFT Evidence monitored by the JHSRC To minimise hazards and reduce risk, requires an effective health and safety risk management system. Risk assessments, using the Trust s Risk Assessment process support this approach and are used to prioritise areas of identified risk or hazard to inform organisational objectives Full site risk assessments are in place for o Slips, trips and falls; o Fire; o Security; and o COSHH. Where appropriate, risk assessments are completed for o Manual handling; o Lone Working; o Stress; and o Display screen equipment. Other risk assessments are carried out as required, for example for expectant mothers During 2016-17 Castleberg Hospital was vacated following risk assessment of the H&S issues. It should be noted that estates related health & safety issues at community sites are under the control of NHS Property Services (NHSPS). Whilst the Trust can influence H&S risks by completing risk assessments and sharing these with NHSPS, we are not able to control the outcome and the risks remain their responsibility. Page 7 of 19

HSG 65 Requirement Check Measure performance (monitor before events, investigate after events) Act Review performance, Act on lessons learned ANHSFT Evidence monitored by the JHSRC Proactive monitoring assesses the achievement of plans and the extent of compliance with standards. Dissemination of relevant safety alerts from organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA), DH Estates and Facilities Department and the National Patient Safety Agency (NPSA) Self-assessment of compliance with Workplace Health and Safety standards Monitoring of action plans, for example those resulting from risk assessments or gap analysis to revised guidance or regulations The self-inspection audit process, based on a database of questions, covers all aspects of H&S and provides for significantly more detailed monitoring, analysis of the results and any identification of gaps. An assurance process ensures the accuracy and completeness of the responses. Reactive systems monitor accidents, ill health and incidents. Adverse event reports are entered onto the Ulysses database; regular reports are produced for all H&S Committees and subgroups, SPI initiative and local governance groups. Further bespoke reports are produced when specific risks are identified. A summary of the H&S findings for this period is presented in section 5. Periodic reviews are undertaken to provide assurance that performance is consistent across the Trust and meets the annual objectives; this includes the Self Inspection Audit. ANHSFT ensures, by regular reporting to the JHSRC that we: Learn from experience; Improve performance; Develop the health and safety management system; and Respond to change. The results of these are reported to the H&S Op Gp and monitored by the JHSRC. Page 8 of 19

5 Achievement of 2015-16 Objectives Table 2 Achievement of 2015-2016 Objectives Objective Status / Progress Further develop assurance of Self inspection audit results Development of support arrangements for staff who have suffered violence and aggression Arrangements for manual handling training Continue to provide a range of responsive Employee Health and Wellbeing services to manage and reduce the number of stress related incidents Collaborative working with the self-inspection audit leads ensures a more robust assurance audit of the responses and required risk assessments. Complete The violence and aggression group has reestablished and more staff have undertaken conflict resolution training. The group continues to monitor any incidents and continues to develop strategies that reduce the risks to staff Manual Handling, Training Needs Analysis has been reviewed and updated. Roll out of the Manual Handling Key Trainer programme to increase department specific training and compliance. Provision of training has significantly increased. Increased department specific sessions provided following the review of the Training Needs Analysis Continue to build the profile and work of the Manual Handling sub group to review incidents and identify patterns and trends. The Employee Health and Wellbeing Service continue to provide a comprehensive range of support. This includes access to the following services: Employee Assistance Programme (EAP) Management and self-referrals to the Employee Health team Counselling Access to the department s dedicated Occupational Therapist Access to Crisis and Post traumatic support Complementary therapy 6 Adverse Events Reports 2016-2017 All incidents and accidents occurring on Trust premises, or affecting Trust staff, are required to be recorded. These reports are collated and analysed using the Trust Incident Management system (Ulysses). Quarterly incident reports demonstrating trends and themes are presented to the JHSRC and H&S Op Gp. In addition specific quarterly reports are discussed at sub-groups covering slip, trip, falls, contamination injuries, manual handling, hazardous substances and violence & aggression. The lessons learnt during the last year are summarised below for the top 6 categories of H&S adverse event reports. Page 9 of 19

Table 3 Lessons identified from the top 6 categories for H&S Adverse event reports Lesson Identified Action Taken 1. Work Related Stress Active promotion of the employee assistance programme (EAP). Within this service staff can seek support for work related stress and up to 6 sessions of telephone counselling. The EAP service has a good knowledge of local support groups and networks and can signpost employees as necessary to these. Employees can self-refer into Employee Health & Wellbeing (EH&WB) for mental health and work related issues. The EH&WB Nurses are trained to support employees through mental health issues and will signpost individuals to the person or group most appropriate for their needs. Where necessary the nurses can make a referral to a counsellor for face to face support. Typically can provide up to 6 sessions but where necessary this can be extended to support the employee A dedicated Occupational Therapist, initially employed on a 12 month project (now permanent), to support individuals absent with work related stress has demonstrated a positive contribution in reducing work related stress and encouraged employees to return to work avoiding 2. Contamination injuries 3. Violence and Aggression, prolonged absences. Contamination end of year report discussed at Infection Control Committee Eye splash and cannula incidents monitored via the quarterly reports Supplies re-assessing needlefree devices Initial work commenced with Supplies to look at non-ported cannulae Teams using non safety devices asked to assess if use is appropriate or if alternatives are now available Quality and safety matters used to deliver key messages. The violence and aggression group has re-established and more staff have undertaken conflict resolution training. Physical Restraint, Breakaway, and basic self-defence sections have been added to the conflict resolution for front line staff. The group continues to monitor any incidents and continues to develop strategies that reduce the risks to staff Investment in CCTV Completing actions from external audit Page 10 of 19

Lesson Identified Action Taken 4. Slips, trips, falls Additional information included in the slip, trip, fall policy relating to prevention and community staff safety. Preventative information communicated to all staff e.g. winter safety information and the incident prevention tables which include telephone numbers for NHSPS service providers. A more robust approach to external surface works, ensuring prompt identification of work required to tie into capital funding monies. 5. Collision with Object Due to the decrease in manual handling issues this cause group has become increasingly significant. A breakdown of the reasons for the collisions is provided in section 6.3.5 below and further investigations will be carried out to establish any mitigating actions that should be 6. Manual handling injuries implemented to decrease reoccurrence. Identified a need to support staff when new equipment or ways of working are introduced, specifically around Moving and Handling this was highlighted when the process for LOLER inspections changed and new linen cages were introduced. Supporting clinical areas when new equipment is required, and following up to confirm that the correct equipment has been sourced Supporting managers and staff with risk assessing potential and actual incidents to ensure escalation to relevant working groups. 6.1 Numbers and Types of Staff Health and Safety Related Incidents Reported The range of incidents received are categorised by Cause 1 allowing further analysis of the reports. Cause 1 categories are used to record individual incident causes, for example contamination injury is divided into 11 individual cause 1s. All reported incidents are then grouped together to provide high level incident causes and allow trends and themes to be identified. Table 4 Provides all reported incidents received by Quality and Safety for the 2016-2017 financial year, date range 01/03/2016 31/03/2017 and compares these to the figures for 2015-2016. Table 4: All Reported Staff Incidents by Cause 1 Cause 1 2015-2016 2016-2017 Trend Work Related Stress* 65 79 Contamination Injuries** 57 76 Slip/Trip/Fall 32 33 Verbal Abuse (inc. racial abuse) 42 28 Violence No Injury 23 28 Collision With Object 29 26 Manual Handling Incident 48 25 Violence With Injury 30 17 Page 11 of 19

Cause 1 2015-2016 2016-2017 Trend Sharps - Cuts In General (Inc. Insect/animal Bites) 4 15 Work Related Risk Concerns ( E.g. Noise, Vibration, Heat) 2 6 Waste disposal 11 4 Trapped/caught in between objects, e.g. door or lid 6 4 Burns And Scalds 6 4 Exposure/contact With Hazardous Substance 10 3 Traffic Accident 6 3 Dermatitis 1 3 Incorrect radiation dose 1 2 Total 373 356 * as reported via Employee Health and Wellbeing ** as reported via infection prevention Overall the number of reported staff incidents for 2016-2017 has remained similar to 2015-2016 following the drop in 2014-2015. There are a several areas showing a significant decrease and this demonstrates the mitigating actions put in place have worked. However, a number of areas have seen a notable increase in the number of reports made. Detailed analysis of the most common events and those where a substantial increase has been noted is provided in section 6.4 below. 6.2 Grade (severity) of incidents Part of the reporting process is to allocate a grading of severity to the incident. None of the reported 356 Health and Safety incidents were graded as red for 2015-2016 this remains unchanged since the 2012-13 report. The grading used is the Trust s standard consequence and impact scoring system (appendix A) as defined in the Risk Management Procedure. To ensure that staff are consistent in their appraisal of the incident, grading is a core component of both induction and mandatory training. Managers are advised to re-review the grade and work collaboratively with staff. 6.3 Top Health and Safety Incident Causes As an organisation we proactively monitor all health and safety incidents with specific reference to the top six. The Trust has encouraged managers and their staff to actively report incidents throughout 2016-2017 and this has increased the number of incident forms being generated. The following table indicates the top six incidents by frequency for 2016-2017 and is compared to the previous reporting year. In addition areas where there has been a significant increase from 2015-2016 have been noted Page 12 of 19

Table 5: Top Six Staff and increased Health and Safety incident causes Top Six Staff Health and Safety incident causes 2015-2016 2016-2017 Work Related Stress* 65 79 Contamination Injuries** 57 76 Violence and Aggression (includes Verbal Abuse, violence no injury, and violence with injury) 95 73 Slip/Trip/Fall 32 33 Collision With Object 29 26 Manual Handling Incident 48 25 6.3.1 Work Related Stress In order ensure these are correctly managed, Employee Health and Wellbeing will be working with HR to triangulate their respective reports and so ensure that managers are referring their staff to Employee Health in a timely manner and individuals are being supported promptly. It should be noted the number of cases reported by Employee Health and HR are independent of those being reported through the adverse incident reporting system. Therefore to improve the accuracy of this report, the Employee Health information drawn from ESR is used. Further actions for 2017-18 include; Improving the accuracy and detail of the data reported by Employee Health. On occasions work related stress is linked to or created by personal stress and may potentially increase the number of actual work related stress cases. The Employee Health and Wellbeing Team are actively working with Remploy to provide Mental Health Support Service (MHSS) on site at Airedale Hospital. This arrangement will provide Airedale staff access to their services and this will be the first time Remploy will be based within an organisation to provide this direct mental health support. 6.3.2 Contamination injuries The number of contamination injuries increased in the year 2016-17 from 57 to 77. Some staff unfortunately had more than one injury (1 member of staff had 5) and this was addressed by EHWB and the Infection Prevention Team (IPT) Matron at the time There were 2 RIDDOR reportable exposures to Hepatitis C. An increase in splash injuries was noted but these occurred during procedures where visors would not have been recommended e.g. splash back from flushing cannulae. Other themes included: not applying safety devices fully and patients moving during a procedure. To address these the company representatives for the safety devices have been asked to provide more training and support. The phlebotomists have a number of new members in the team so there is also likely to be a resulting increase due to lack of experience. This should improve as they develop their skills and the IPT have provided additional training around contamination injuries to the phlebotomy team The Contamination Injuries Working Group which reports to the H&S Op Gp continues to investigate reported incidents and provides a consistent approach in Page 13 of 19

monitoring key trends and sharing of lessons learnt. The EH&WB and IPT provide feedback to the group on their investigation of contamination injuries and the recent introduction of clinical membership to the group has enhanced the overall assessment and implementation of actions post incidents. The working group also correlate reports to ensure consistency of actions taken, for example the raising of awareness through sharps safety and incident reporting at both induction and mandatory training sessions. Further actions 2017-18: Continue with Contamination Injury Working Group Standardise needlefree access devices Evaluate and introduce non-ported cannulae Publish key themes in Quality and Safety Matters 6.3.3 Violence and Abuse (all types) Conflict resolution training available to all staff; Risk assessment completed and escalated through the DAGs to Executive Lead (Director of Operations) Further actions for 2017-18 include Phase 2 of the access control system to include proximity access to wards and utility rooms, additional CCTV in these areas. More CCTV in external areas 6.3.4 Slips, Trips and Falls Although the figures for 2016-2017 have only increased by 1 from the previous financial year, a slight increase in RIDDOR reported incidents has been noted. To address this, the following proactive measures have been implemented External risk assessments reviewed, high risk areas identified and funding sourced for external works. Slip, trip, fall section, including proactive reporting of hazards and risks, contained in corporate quality and safety training and the self-inspection audit process. Mini Place audits at Airedale and Community Site Hospitals. Results of external slip, trip, fall external risk assessments at Settle Health Centre and Skipton General Hospital communicated to landlord to enable them to incorporate into their capital works. Circulation of information to staff, including community incident prevention sheet and staff safety winter reminder. Workplace Occupational Health and Welfare Slip, Trip, Fall standard updated to add information from the proactive slip, trip, fall risk assessments. Slip, trip, fall policy reviewed and ratified. Claims information fed through to the Slip, Trip, Fall Group to identify trends and themes and identify additional learning. Further actions 2017-18: Continue with ongoing proactive work described above. Continue to develop the self-inspection audit and H&S compliance assurance for the Trust. Further analysis of adverse event forms to identify any reasons for increase in incidents in quarter 4 for the past 2 financial years and to identify further learning/actions. Page 14 of 19

6.3.5 Collision with Object This is a new entry into the top 6 this financial year a breakdown of the incidents shows a range of collision types. Type of Collision Equipment in environment 9 Pushing/pulling/mobilising equipment, e.g. something falling off something when pushing or pulling, not harm from manual handling Cleaning 5 Other 5 Number Further actions 2017-18: Consider addition of information slide to Quality and Safety mandatory training Analyse the incidents in more details to identify any learning Continue to monitor to see if trend continues 6.3.6 Manual Handling Manual Handling incidents have seen a small increase on the previous year. The manual handling assurance sub-group continues to spend time focusing on manual handling adverse event forms on a quarterly basis. Part of the sub-group s task is to confirm that all AEF s have been investigated, and there are appropriate outcomes and or actions relating to the specific incident, and chase up any additional information. The sub-group also monitor the AEF s to identify if there have been any common themes or patterns. As the key trainer model continues to develop, the membership of the group will increase allowing for increased sharing of knowledge and skills from across the trust. This will increase provision and contribute to increase in compliance. It will also give each area access to a specifically trained expert in manual handling who can contribute to risk assessments and training. Further actions for 2017-18 include Continue to develop the key trainer model and ensure offered to all staff in both clinical and non-clinical areas. Review the overall offer to ensure it is still fit for purpose and reflective of the workforce needs. 6.3.7 RIDDOR reporting ANHSFT are required to report specific injuries and any absence of over a defined period to the Health and Safety Executive (HSE) via the RIDDOR reporting system. The following table indicates the total number of staff incidents reported for 2015-2016 compared to 2016-2017 Table 6: RIDDOR Reportable Events Q1 Q2 Q3 Q4 Total 2015-2016 2 4 0 7 13 2016-2017 2 2 2 8 14 6 Page 15 of 19

As can be seen the number of RIDDOR reports has remained consistent. In 2016-2017 the incidents involved 4 manual handling incidents, 4 slip, trip, fall incidents, 2 contamination injuries and 1 bite leading to risk of hepatitis B & C exposure. There was also 1 case of occupational dermatitis, 1 traffic accident and 1 staff unwell unexpected. 6.3.10 Fire All areas had a fire risk assessment carried out in 2016-2017 and any significant findings were recorded. All rectification work was passed on to estates and projects; the rectification work has commenced and is scheduled through the next financial year. Every ward and department had a fire drill in 2016-2017 to test local procedures, all wards and departments passed the drill providing assurance the procedures will work in a real fire situation. Throughout 2016-2017 there were a total of 38 false alarms all were dealt with on site and none became unwanted fire signals (an unwanted fire signal will incur a cost, typically around 450 per fire engine.) In Summary Health and Safety is recognised by ANHSFT to be fundamental in the delivery of safe services for staff, patients, carers and visitors. Progress to ensure that the organisation meets the requirements for health and safety legislation was consistent throughout 2016-2017. Going forward, based on the details contained within this report, the annual plan for 2017-2018 will continue to progress its management of health and safety across the Trust, with particular focus on Assurance of Self inspection audit results Development of the Violence and Aggression sub-group and related support arrangements for staff who have suffered violence and aggression Continue to provide a range of responsive Employee Health and Wellbeing services to manage and reduce the number of stress related incidents Improvement in Mandatory Training Rates Development of H&S risk assessment competencies across the Trust Carol Woolgar Resilience and Governance Manager Dawn Bracewell Health and Safety Coordinator Mel Jackson Fire Safety Officer and Security Manager Michael B Smith Head of Employee Health and Wellbeing Matthew Smales-Cresswell Training and Education manager Page 16 of 19

Allison Charlesworth Matron Infection Prevention May 2017 Page 17 of 19

Appendix A Adverse Event Scoring Criteria Table 1: Consequence Grades 5=Catastrophic Death, malicious or otherwise and/or significant loss of reputation for the Trust and/or loss of key Trust services which prevent the Trust meeting its responsibilities 4=Major 3=Moderate 2=Minor 1=Insignificant Permanent injury, amputation, major damage and/or start of a national investigation into the Trust and/or disruption of key Trust services which significantly hinder the Trust in meeting its responsibilities Semi-permanent injury or damage(recovery takes longer than 1 month but no more than 1 year) and/or adverse publicity for the Trust Short term injury or damage (recovery within 1 month) No injury or adverse outcome Table 2: Likelihood Grades 5=Almost Certain A persistent issue (more than once a week) 4=Likely Will probably occur (once or twice a month) 3=Possible May occur occasionally (once or twice per year) 2=Unlikely Do not expect it to happen but it is possible (once every 3 to 5 years) 1=Rare Can t believe this will ever happen (that is to say not in the next 5 years) 76 100% 51-75 % 26 50% 6 25% 1 5% Table 3: Classification Matrix Most likely Impact/Consequences Likelihood of None Minor Moderate Major Catastrophic occurrence/ (1) (2) (3) (4) (5) recurrence Almost certain (5) 5 10 15 20 25 Likely (4) 4 8 12 16 20 Possible (3) 3 6 9 12 15 Unlikely (2) 2 4 6 8 10 Rare (1) 1 2 3 4 5 Classification of Incident Page 18 of 19

Very Low Low to Moderate Moderate to High High Monitored Executive Management Committee by Risk Monitored by The Trust Board Page 19 of 19