Serious Incident Management Toolkit - Appendix 1 - Serious Incident Review Toolkit

Sep 13, 2026

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Serious Incident Management Toolkit and Appendix 1 set out a clear approach for Cwm Taf Morgannwg University Health Board to identify, report, investigate, and close serious incidents meeting Welsh Government criteria. It defines serious incidents across unexpected or avoidable death, severe harm, Never Events, abuse allegations, and incidents threatening service delivery or public confidence. The toolkit covers immediate actions, escalation and notification steps via DATIX and central processes, investigation workflow, learning capture, and assurance mechanisms including templates for reports, records, grading, and checklists.

LanguageEnglish

CategoryForms

FormatPDF

Pages33

Reading Time12 min

AccessFree to download

Purpose

Definition of a Serious Incident (SI)

Phase 1: Immediate Actions

Phase 2: Determine if an SI (Refer to Definition)

Phase 3: Investigation Process

Phase 4: Learning From Events

Appendix

Document Checklist

How to manage Serious Incidents in Cwm Taf Morgannwg University Health Board Serious Incident Management Toolkit | Lead: | Patient Care & Safety Unit | | --- | --- | | Approved by (pending): | Quality & Safety Committee | | Approved date: | November 2020 V3 | Serious Incident Management Toolkit | Page | Section | | --- | --- | | 3 | Purpose | | 3 | Definition of a Serious Incident (SI) | | 4 | Phase 1: Immediate Actions | | 4 | Phase 2: Determine if an SI (Refer to Definition) | | 6 | Phase 3: Investigation Process | | 8 | Phase 4: Learning From Events | | 9 | Appendix:
1. Serious Incident Meeting Agenda
2. Investigation Report Template
3. Investigation Crib Sheet
4. Learning from Events Record
5. Assurance Checklist
6. Level of Harm Grading Framework | | 31 | Flowchart 1 | | √ | Document Checklist | | --- | --- | | | Tabular timeline | | | SI notification form submitted by CTM to WG | | | Investigation report and summary of tools used e.g. RCA, statements | | | Action plan | | | SI closure form submitted by CTM to WG | | | QA checklist completed by CTMUHB staff for that incident | | | Evidence of how learning identified through the investigation embedded/led to change | Why do we need the SI Toolkit? Purpose The Serious Incident (SI) Toolkit has been developed to provide a clear and consistent approach to the identification, reporting, investigation and closure of incidents meeting the criteria, as set out by Welsh Government. Definition of a Serious Incident (SI) A serious incident is defined as an incident that occurred during NHS funded healthcare (including the community) which resulted in one or more of the following:- 􀂾 Resulted in unexpected or avoidable death or severe harm of one or more patients, staff or members of the public; 􀂾 A Never Event – all never events are defined as a serious incident although not all never events necessarily result in severe harm or death. 􀂾 A scenario that prevents, or threatens to prevent, an organisation's ability to continue to deliver healthcare services; including data loss, property damage incidents or incidents in population programmes like screening and immunisation where harm potentially may extend to a large population. 􀂾 Allegations, or incidents, of physical abuse and sexual assault or abuse; 􀂾 Loss of confidence in the service, adverse media coverage or public concern about healthcare or an organisation. PTR Guidance link [http://www.wales.nhs.uk/governance-emanual/putting](http://www.wales.nhs.uk/governance-emanual/putting)things-right Allegations, or incidents, of physical abuse and sexual assault or abuse can relate to staff, patients or a member of the public. Consideration should be given as to whether a Serious Incident or No Surprises is required. A proportionate review / investigation should be undertaken. This toolkit is to be applied for serious incidents where there is no agreed investigation tool in place. Investigation Tools currently in place within the Health Board relate to: 􀂾Pressure Damage 􀂾Inpatient Falls 􀂾Patients Absent Without Leave (AWOL) 􀂾Infection Prevention & Control 􀂾Ionising Radiation Medical Exposure Regulations, (IRMER) 􀂾Unexpected Deaths in Mental Health For further support or guidance please contact your ILG Leads or the Corporate Patient Safety Team via [CTHB_Patient_Safety_Incidents@wales.nhs.uk](CTHB_Patient_Safety_Incidents@wales.nhs.uk) We Treat Everyone With Respect | Immediate Actions | | | | | --- | --- | --- | --- | | Actions | Responsibility | Useful Information | Timeframe | | Implement immediate make safe actions to ensure patient safety and reduction of risk. Consider the need to notify the Communication team. Identify if Safeguarding referral to be submitted.
Contact MASH if required. | ILG | No Surprises to WG if required
E mail to central Inbox:
CTHB_Patient_Safety_Incidents@wales.nhs. uk
CT MASH 01443 743730
Bridgend MASH 0

FAQs

What qualifies as a Serious Incident (SI) under this toolkit definition?

An SI includes unexpected or avoidable death or severe harm, Never Events, allegations or incidents of physical abuse and sexual assault or abuse, scenarios that threaten an organisation’s ability to deliver healthcare services, and situations involving loss of confidence or adverse media/public concern.

What immediate actions should be taken when an incident occurs?

Implement make-safe actions to ensure patient safety and reduce risk, secure relevant evidence, report the incident through DATIX/verbal escalation, support staff using Just Culture where applicable, and consider safeguarding referrals and communication notification needs.

How is it determined whether the SI threshold has been met?

If unclear, a Review And Prioritisation Incident Discussion (RAPID) is held within the unit with identified professionals not directly involved. If criteria are met, SI reporting and the appropriate investigation level and investigating officer are agreed.

Sep 13, 2026

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