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Oxleas Incident/Near Miss Reporting Form - October 2023

Thank you for completing this Incident Report

All newly confirmed positive COVID-19 cases for in-patients should now be reported on Datix

If you require help completing this form, please contact the Patient Safety Team at Pinewood House via oxl-tr.datixweb@nhs.net.

Where death or serious injury has occurred this must be reported immediately by following the Oxleas Incidents Management policy

Indicates Mandatory fields (you must complete these fields before submitting form

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You will receive a Feedback notification email containing the Investigation and lessons learned once this incident has been Finally Approved.

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Incident details

Incident date (dd/MM/yyyy)
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Incident time (hh:mm)
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Please select the appropriate time band for the incident.
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Description
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Enter facts, not opinions - where, what, when, how, why? Do not enter names of people (use initials ONLY) or other identifiable information.

Immediate Actions Taken
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Enter actions taken at the time of the incident. Do not enter names of people(use initials ONLY) or other identifiable information.

Notify
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Please tick any options in the list you wish to notify, you may select more than one

None required
Health and SafetyTeam
Safeguarding Children concerns
Safeguarding Adults concerns (For all prison staff please ensure you follow local practice for safeguarding referrals)
Infection Control Team
Tissue Viability Nurse
Police informed / contacted for assistance
Attended A&E / UCC / Minor Injury Unit
Ambulance / crash team called for assistance
Fire service contacted for assistance
Operation Mettalah protocol
Estates
Confidential reflection with a PNA

Safeguarding Adults

Incidents Classification

Type
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Category
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Sub category
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Abuse and Aggression Content
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You can select more than one if applicable.

Age
Disability
Gender
Gender Identity (e.g Transgender)
Marriage / Civil Partnership
Pregnancy
Race or Ethnicity
Religion or Beliefs
Sexual Orientation
Not applicable

Other - Accident
You must enter a value in this field

Safeguarding Children

Were ligature cutters used?

Security

Racist Language

Sexist/Sexual Language

Blanket restriction

Did a blanket restriction contribute to this incident?
You must enter a value in this field

Breakaway

Were breakaway techniques used in this incident?
You must enter a value in this field

Restrictive Practice

Mental Health Act

Information Governance Breach

Sleepover conditions

Please complete the sleepover conditional questions below.;

Pressure ulcer further information

Security & Violence towards Staff

RIDDOR reportable?

RIDDOR

Reporting of Injuries, Diseases and Dangerous Occurrences Regulations: certain defined incidents which need to be reported to the HSE - those causing major injuries; those resulting in staff being off work for more than 7 days; certain work related diseases; certain dangerous occurrences (serious near misses). Contact the H&S Team if you think it may be a RIDDOR incident so this can be confirmed.

Equipment

MARAC / Domestic Violence

Has a referral been made to MARAC / Domestic Violence?

Medication incident details

Further Information Regarding Fall

Incident Severity and Result

Please refer to the Oxleas Incidents Severity Chart which will help you decide the severity level of the incident Please ensure all SIs (level 4 and 5) are immediately escalated to the service manager and service director. Please ensure The Ox is open on your computer for this link to work.

Result
You must enter a value in this field

Degree of Harm
You must enter a value in this field
This is the Actual harm caused to the person affected/injured

Severity (Please Choose Only ONE)
You must enter a value in this field
The severity relates to the harm that the incident caused to the person involved and is linked to the level.

Level 1 - No Harm
Level 2 - Minor Harm (e.g requiring minimal or no medical attention or EXPECTED natural causes death)
Level 3 - Moderate harm (e.g. Restraint, Sexual Incident, Short Staffing and incidents requiring medical attention)
Level 4 - Severe Harm (e.g. severe / permanent harm or UNEXPECTED death)
Level 5 - Serious Incident (e.g. severe / permanent harm or death in and OXLEAS inpatient setting)

Duty of Candour

Patient / Staff/ Unit (team) that was or could have been injured by this incident.

Person(s) or unit/team affected

Clear Section

Who was involved/affected in this incident?
You must enter a value in this field
This is the person(s) who has been directly INVOLVED in the incident e.g the VICTIM of the incident.
All other contacts can be included within the additional information sections below e.g perpetrator, witnesses etc

Type
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Subtype
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First names
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Surname
You must enter a value in this field

Patient/staff number
You must enter a value in this field

Ethnicity
You must enter a value in this field

Job title
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Telephone no. 1
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E-mail
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Date of birth (dd/MM/yyyy)
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Unit/Team
You must enter a value in this field
Please select your team from the drop down or start typing the name in the dropdown menu

Demographics

Was this person injured?

Injury Details

LFPSE Contact Fields

What is the patient's sex?
You must enter a value in this field

What is the patient's self-identified ethnicity? $Help (What is the patient\'s self-identified ethnicity?)$
You must enter a value in this field

To what extent was the patient physically harmed (including pain) in this incident?
You must enter a value in this field

To what extent was the patient psychologically harmed in this incident?
You must enter a value in this field

How much did the incident contribute to the outcome for the patient?
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What was the clinical outcome for the patient?
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Additional Information

Was there any other contact involved? e.g alleged perpetrator?
You must enter a value in this field

Was any employee involved in the incident?
You must enter a value in this field

Were there any witnesses to the incident?
You must enter a value in this field

Are there any documents to be attached to this record?
You must enter a value in this field

Was this incident received via a 3rd party?
You must enter a value in this field

Is this patient on End of Life Care?
You must enter a value in this field

Lone Working

Alledged Perpetrator

Employees

Please complete details for ALL staff involved.

Witnesses

Documents

Incident Location - where the incident occurred.

Team
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Speciality/Department
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Borough
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Directorate
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CQC Location
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Location (type)
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Location of Incident
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Details of person reporting the incident

Reporter

Clear Section

Subtype
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First names
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Surname
You must enter a value in this field

Job title
You must enter a value in this field

Telephone no. 1
You must enter a value in this field

E-mail
You must enter a value in this field
NHS.net email account only

Do you require progress updates on this incident?
You must enter a value in this field

Yes

Your Manager

Please select the person who will be investigating this incident - e.g Your Line Manager

Your Manager
You must enter a value in this field

LFPSE

LFPSE - Risk

LFPSE - Went Well

LFPSE - Medication

LFPSE - Equipment

LFPSE - IT Sytems & Software

LFPSE - Tissues & Organs

LFPSE - Involved Persons

LFPSE - Reporter

LFPSE - Adverse Event Agent

LFPSE - Adverse Event Problem Buildings Infrastructure

LFPSE - Adverse Event Problem Estates Services

LFPSE - Adverse Event Problem Blood

LFPSE - Adverse Event Problem Blood Products

LFPSE - Adverse Event Safety Challenges

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