National Health Service

England – London

Primary Care Significant or Serious Incident - Notification Form

The purpose of this form is to comply with national guidance and enable timely information sharing and
facilitate learning from Serious Incidents (SI’s) requiring Investigation, and Significant Event Audits (SEAs)
in Primary Care. Please complete this form with as much detail as possible.
Please email your form to: [email protected] NHS England Ref: ________________________

DO NOT INCLUDE PATIENT IDENTIFIABLE INFORMATION OR THAT OF INDIVIDUALS OTHER THAN THOSE
OF THE REPORTER FOR COMMUNICATION PURPOSES.
In your opinion is this incident a Significant Incident (SI) SIRI ☐
or a Significant Event Audit (SEA)? (See below for definition of incidents) SEA ☐
When, Where and Your Details

Type of Incident (a) Reporting Organisation:

(Please see appendix for list of Incident types) Royal London Hospital, Whitechapel, London
Access, admission, transfer, discharge

Further descriptor for incident (b)

Missing patient

Date of Incident: Reporter Name:

February 21, 2020 Kyla L. Madjad, RN

Time of Incident: Reporter Job title/Role:

4:05pm Nurse I

Location of Incident: Reporter Tel No:

Royal London Hospital – Ward 5 020 8871 1788

Date Incident Identified: Reporter Email:

February 21, 2020 [email protected]

Name of other Organisations Involved (where relevant):

eg: GP Practise, Hospital, Ambulance Service, OoH, Care Homes, Mental Health Services, Police, etc.

City of London Police Service

Care Sector:
eg: General Practice, Dentistry, Pharmacy, Optometrists, Other. If Other please specify.

General practice
Patient Details This information should only be supplied if this form is transmitted via a secure transmission –
NHS.Net email account or a safe haven fax – please do not include patient name or other patient identifier.

Patient Date of Birth: Patient Gender:

10/01/12 Male

Patient Registered GP Practice: Patient Ethnic Group:

Dr. Chad Jumurin Filipino

Patient NHS Number:

231 312 1234

What Happened?

Description of What Happened including how the SI/SEA was identified:

The nurse-in-charge was about to administer the 4pm medication when the patient was found missing from
his bed. The patient was last seen at around 1pm lying supine on the bed, sleeping, with significant other
(mother) at the bedside. The patient was wearing a plaid jacket with pants.

Immediate Action Taken:

The nurse-in-charge immediately started searching the patient’s room. After clearing the room, the incident
was immediately reported to the nurse supervisor on duty.

Any Further Information:

The mother was not in the room upon discovery of the incident. Code yellow stages 1 to 3 were implemented
according to hospital protocol. The mother failed to inform the healthcare staff of the patient’s severe
separation anxiety.

Details of any Police, Media Involvement/Interest:

Police was involved with the search as the search area was expanded beyond the hospital’s vicinity.

Please indicate which other organisations have been notified?

CQC IG Toolkit HSE MHRA NRLS CCG

Details of contact with or planned contact with patient/family or carers:

The mother was notified by the nurse supervisor within 10 minutes of receiving the report as part of the
protocol for the first stage code yellow.

Learning Outcomes:

What lessons might be learned and shared with others?

Improve patient communication especially for immigrants to elicit more information on both the patient’s
medical history and present medical condition.

Have you identified any factors you are not in a position to change?
Adding more CCTV cameras in the hallways and employing more multilingual staff.

ACTION POINT WHO BY WHEN

Adding more CCTV cameras in the building. Hospital administration Soonest possible

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Increasing staff (i.e. additional translators, exit and Hospital administration Soonest possible
entrance guards)

Apparent Outcome of Incident: Patient was found after three (3) hours. Patient was not harmed.

Please describe: The patient passed through the fire exit of the building. He went as far as the next block in
search for his mother. No physical injury was observed upon assessment of the patient; hence, no actual harm
was inflicted to the patient. However, potential severe harm could have ensued as the patient was

Please categorise significance/potential significance (tick A for actual harm and P for potential harm)
Definitions of harm can be found in the National Framework.
None Low Harm Moderate Harm Severe Death
Harm

P P P /P P
/A A A A A

Likelihood of Reoccurrence:
Before reviewing this event – Please attempt to assess the likelihood of a similar event happening again.
Almost certain Likely Don’t know Unlikely Rare

Definition of Serious, Significant and Never events

SI - Definition of a Serious Incident - The definition of SEA - Definition of a Significant Event - The Royal
a ‘Serious Incident’ is set out in the ‘Serious Incident College of General Practitioners (RCGP) states that
Framework March 2013 – (NHS England Patient Safety significant events suitable for analysis are events where the
Domain). Broadly, ‘Acts and/or omissions occurring as practitioner can identify an opportunity for making
a part of NHS funded healthcare’ , including the improvements, either because the outcome was substandard
community) that resulted in; or because there was a potential for an adverse outcome
(‘near miss’), but these incidents involve a lower level of
• Unexpected or avoidable death, serious harm, injury, safety concern than a ‘serious incident’
abuse, psychological or psychological; or where
healthcare did not take appropriate action
• or a Never Event – see never events policy.
• Or an event that seriously prevents or threatens to
prevent an organisations ability to continue to deliver an
acceptable quality of healthcare.

APPENDIX - Incident Types a) and further information b)

Type of incident a) general Type of incident b) descriptor

Access, admission, transfer, discharge (including missing
Cold chain
patient)
Clinical assessment (including diagnosis, scans, tests,
Communication - 111, Out of Hours
assessments)
Consent, communication, confidentiality Communication failure
Disruptive, aggressive behaviour (includes patient-to-
Confidentiality & Communication - Breach of confidentiality
patient)
Documentation (including electronic & paper records,
Consent - failure to gain consent
identification and drug charts)
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Implementation of care and ongoing monitoring / review Diagnosis - delay, failure to
Infection Control Incident Diagnosis - wrong
Infrastructure (including staffing, facilities, environment) Discharge - delay, failure
Medical device / equipment Do not resuscitate (DNR)
Medication Documentation - missing, delayed, inadequate
Other Documentation - patient incorrectly identified
Patient abuse (by staff / third party) End of Life issue
Patient accident Healthcare professional issue
Self-harming behaviour Immunisation, vaccination
Treatment, procedure Infection control - Cdiff
  Infection control - MRSA
  Infection control - Other
  IT system failure
  Prescribing/Dispensing - lost prescription
  Prescribing/Dispensing - Other
  Prescribing/Dispensing - preparation incorrect
  Prescribing/Dispensing - wrong dose, quantity
  Prescribing/Dispensing - wrong drug
  Prescribing/Dispensing - wrong label
  Prescribing/Dispensing - wrong patient
Prescribing/Dispensing - EPS
  Pressure ulcer
  Professional Registration issues
  Referral - delayed 2WW
  Referral issue
  Safeguarding concern
  Scans, X-rays, specimens
  Screening incident
  Sepsis
  Sharp incident
  Slip, Trip, Fall
  Suicide suspected
Test results or reports - failure to report, act, receive,
 
incorrect, missing

This form should be completed and sent to NHS England South West (South) as soon as possible to when the
incident was identified.

Email your form to: [email protected]

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