It is a mandatory requirement for health care organisations to have learning event reporting policies and procedures in place. This is an important part of good risk management and informs the organisational liability with respect to insurance and indemnity cover.
The reporting of both clinical and non-clinical learning events of any level of severity, and including significant events and near misses (hereafter referred to as learning events), is fundamental to BrisDoc’s risk management strategy. BrisDoc has a statutory duty to ensure that all users of provided services are cared for in a safe environment; that staff can work in a safe environment; and that risks are reduced to a minimum. This is also consistent with BrisDoc’s values as set out in the four-way model. It is the responsibility of all staff employed by or working on behalf of BrisDoc to report learning events, significant events, and near misses through the reporting framework identified in the learning event reporting procedure (appendix 1). It is their duty to report those learning events in which they are directly involved and those of which they are aware.
This policy will be operated within a learning environment, where lessons are learned and quickly acted upon in a positive and constructive way.
BrisDoc actively promotes a non-punitive approach to learning event reporting and will fully support any individual reporting a learning event. In many instances, the root causes of learning events lie in the management and organisational systems that support the delivery of care. In this case, blame cannot, and should not, be attributed to individuals. The essence of BrisDoc’s reporting procedure is to identify and address the underlying causes of learning events. All learning events will be investigated in accordance with best practice and processes, and managed in a sensitive and non-punitive manner. Learning events that have caused harm or created the potential for harm to a patient will be notified to the insurer. BrisDoc will comply with its duty of candour to inform patients where their diagnosis, care or treatment has caused actual or potential harm in accordance with its Being Open Policy.
Disciplinary procedure will only be considered in the following cases:
- Repeated error involving the same individual, where the error has been highlighted and learning identified.
- Deliberate failure to report a learning event
- Failure to cooperate with an investigation
- Criminal actions
- Actions so far removed from reasonable practice that any competent practitioner/ member of staff would have been able to predict the outcome.
It is BrisDoc policy that all learning events are:
- Reported via the learning event portal in the staff weblinks page on the BrisDoc website (https://learning event.brisdoc.co.uk)
- Investigated, and where appropriate an action plan (appendix 2) put in place within 1 month of the date of the learning event being reported
- Risk assessed (appendix 3)
- Significant learning events are investigated using the root cause analysis approach (appendix 4)
- Reported to external bodies (including statutory agencies) in the timescales required when necessary.
When a learning event is received, a discussion needs to take place and a decision needs to be reached as to whether the matter requires notification to Insurers. The decision process and outcome should be documented on BrisDoc’s Learning event Reporting Information System (LERIS) or GP TeamNet for future consideration, even where the decision reached is not to notify.
Medical negligence occurs where a medical professional has provided care that was below a reasonable standard, resulting in bodily injury (which could also include mental anguish) or a mis-diagnosis. Since April 2019 NHS Resolution has provided clinical indemnity for primary care under the Clinical Negligence Scheme for General Practice (CNSGP) which requires notification when a letter of notification or claim is received by the provider. CNSGP does not cover any private primary care, services provided by primary care that are not covered by the GMS/PMS/APMS contract, or legal support/cover required for inquests/claims. If a complaint reveals a claim for medical negligence, or if it is considered that there is even a low risk of legal action, the case must be notified as a circumstance to AJG Insurance as soon as possible and a notification form must be completed. No correspondence should be issued to a complainant or their representative in connection with a claim or potential claim without prior authorisation of the insurers.
If there is ever any doubt regarding whether a learning event is reportable to insurers, then it should refer the matter to AJG Insurance as soon as possible.
The decision to notify should be reviewed and the decision documented at each stage of the investigation process and AJG Insurance notified as and when required.
All serious untoward learning events should be reported as soon as possible to our insurance company, via the Governance Team.
Some learning events may be appropriate for notifying to BrisDoc’s employee and public liability insurers.