Critical Incident Policy (procedures for reporting, investigating, and sharing lessons learnt).
Updated May 2025
Purpose
The purpose of this policy is to outline the response for Atrium Clinicians when a critical incident arises within their place of work. It covers how to report an incident using the form attached, how incidents will be investigated, how policies and processes will be revised to accommodate learning from those incidents and how that learning needs to be shared with partners and stakeholders.
What is a critical incident
Critical incidents are incidents and events of any scale outside of the usual business activity that can result in serious consequences. They can be both operational and non-operational. What follows are examples only and are not exhaustive:
- operational
o death of any person relating to Atrium client work
o serious injury to any person
o hostage taking of any person
o terrorist attack
o attempt of suicide or self-harm
o arson
o assault
o escape from detention
o encounter with serious crime
o riot or public disorder
o media presence or involvement
o multi-agency “blue on blue” incident
o industrial action
o serious corruption or criminal acts
o local security threat
- non-operational:
o pandemic
o legal action
o serious data breach
o breach of procedure
o corruption, misdemeanour, or crime
o a specific high-profile case for example one involving public figures or one which brings the individual clinician, Atrium, or place of work into adverse media attention.
Process of response
With any critical incident an assessment is to be conducted by clinician, to gain current and ongoing information, in line with policy, to ascertain risk to clients, self and others. Part of this assessment is to liaise with direct line manager.
Critical Incident Risk
Once an assessment has been conducted in line with policy and discussion with line managers, action, if necessary, can be taken by clinician if advised to by Atrium. If unsure, they must liaise with line manager.
In this policy not all actions can be determined as several factors determine any action to be taken with varying critical incidents. The clinician is expected to discuss and agree appropriate action.
Operational Incidents
Within the scope of community settings, type of actions to be taken for operational incidents, such as self-harm or suicide attempts, corruption, assault, threats. These actions are in line with other relevant policies and action should be taken appropriately.
- Email or telephone line manager /service lead first and pathway team for advice. If email mark important.
- Clinical Supervision and Line manager involvement
- Liaising with relevant coordinating team and services to ensure risk and safety is coordinated.
Non-Operational Incidents
For non-operational incidents, actions to be taken in line with other training and policies.
- Email Line manager /mark important
- Clinical Supervision and whether additional parties need to be informed e.g. Landlord, referring agencies
Those critical incidents out of the scope of these procedures are always to be discussed with line manager. Complete Critical incident form as a priority after notifying the manager/pathway team.
Accurate, complete, and detailed decision logs are crucial to the successful management of any critical incident. Every decision, however minor, must be logged by email ensuring that the rationale behind the decision is recorded accurately. At the conclusion of any incident, these logs will be made available to the officer conducting the debrief, and if appropriate, to the investigating authorities and the courts. There are practical difficulties of managing an incident whilst maintaining full and accurate notes therefore it is recommended that wherever possible clinicians are accurately reporting with support of supervisor in any incident. Clinician notes must be of a standard that would allow the someone to return to them up to 7 years later, and know why a decision was made, and defend that decision if necessary.
- Sharing the lessons
Atrium Clinic is committed to being open and transparent. When incidents or near misses occur, we will investigate them to ascertain the facts so we can learn from them. Sadly, and occasionally, our clients come to harm by suicide or are seriously injured and we will always actively take part in hearings and enquiries to discover how we can improve what we do and work well in a team. We invite and accept feedback on our practice and offer feedback to our colleagues too in the interest of client safety and the improvement of mental health services. We also use quarterly meetings with our commissioners of services to report ‘near misses’ and critical incidents so we can learn together and resolve issues early.
Critical incident form below
Critical incident report including ‘Near Miss’ incidents.
Name…………………………..
Telephone and email contact………………………………
Consultant or Employee …………………………………..
Date of incident and date of report…………………………………
Location of incident/full address and contact details
Type of incident – Please tick
Death
Injury
Abuse/Harassment
Corruption
Disease outbreak
H& S
Service management
Cyber security breach
Crime/theft
Other
Near miss? Actually happened? ………………….
What happened? …………………………….
Who else is involved? Site managers, perpetrators, clients…….
Has Atrium manager been informed?
Pathway team?
What was the advice given?
Have you followed advice given?
