Blackpool Council patient safety incident response plan

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Effective date: March 2025

Estimated refresh date: March 2026

Introduction

This patient safety incident response plan sets out how the Blackpool Council Positive Steps into Work Service (PSIW) intends to respond to patient safety incidents over a period of 12 to 18 months.

To help develop our PSIRF plan and policy we have reviewed our safeguarding/harm data and have consulted with staff in order to identify areas of priority.

It is anticipated that this plan will evolve over time. We will remain flexible and consider the specific circumstances in which patient safety issues and incidents occurred and the needs of those affected.

This plan should be read in conjunction with:

PSIW PSIRF Policy
Blackpool Council accident/incident/near miss reporting policy (available on request by email to positivesteps.intowork@blackpool.gov.uk)
Blackpool Council accident investigation policy (available on request by email to positivesteps.intowork@blackpool.gov.uk)
PSIW safeguarding policy and procedure (available on request by email to positivesteps.intowork@blackpool.gov.uk)

Our services

Positive Steps into Work is a Blackpool Council service designed to encourage unemployed people back into work and, at the same time, help local businesses to recruit local people into their jobs.

It is all part of our commitment to regenerating Blackpool and making it a better place to live, work and do business.

PSIW does not provide health care services. We provide employment advice to individuals, including individuals who are receiving or have received care from NHS organisations. In some circumstances, these employment advice services are commissioned by NHS commissioners under the NHS standard contract.

Support for individuals

We offer a free service to people who are out of work. We provide support, including an experienced employment adviser, and advice to help people back into employment. We assist with finding training courses and work placements, writing CVs, helping with job applications and interview preparation including in certain cases paying for interview clothes or work equipment.

We provide employment support and advice to individuals in the community including those receiving NHS care.

Support for business

We offer a full recruitment service which includes but is not limited to discussing workforce needs, helping businesses produce job descriptions so that they can find staff with the right skills and qualities, providing CVs, organising interviews, and finding venues for interviews, if required.

We also provide up-to-date information on any schemes that might help businesses to grow and access to funding for free training from local training providers or recruiting Apprentices.

Where PSIW are commissioned by the NHS to help individuals who are receiving NHS care PSIRF methodology will be followed in the event of any incidents.

Defining our patient safety incident profile

To identify the patient safety issues most pertinent to PSIW we have reviewed the following patient safety incident information:

Analysis of four years of incident data from 2020 to 2024
Key themes from complaints

Defining our patient safety improvement profile

We have defined our top local patient safety risks based on potential for harm and likelihood of occurrence having considered the services provided and previous accident/incidents reported:

Details of risk
Risk	Improvement and transformation work
There is a risk that a deterioration in a patient's mental health condition may be noted by PSIW staff but that staff may not be aware of who to alert.	Work has been completed to update the PSIW referral form to include a section detailing the patient's key contact for mental health care, for example, a social prescriber or mental health practitioner, so that in the event that there is a deterioration in a patient's mental health PSIW staff can quickly alert the patient's key contact.
PSIW staff may not understand what is meant by patient safety, rather than safeguarding, and may struggle to identify patient safety issues.	Specific patient safety training now forms part of our staff induction process.

Our patient safety incident response plan: national requirements

Our staff are required to report all accidents, incidents and near misses to line management (or in the case of a fatality to senior management) in accordance with the Blackpool Council accident/incident/near miss reporting policy. PSIW will continue to investigate any incidents in accordance with Blackpool Council policies.

In the event that an incident occurs which involves a service user who is receiving inpatient or outpatient care at an NHS Trust, it is anticipated that the Trust will lead the investigation and learning response in accordance with the Trust's PSIRF plan and policy and PSIW will provide input as required/requested, complying with PSIRF. In cases where the Trust does not lead the PSIRF investigation or it would not be appropriate for them to do so, then PSIW will take the lead in accordance with this Plan and the supporting Policy.

In accordance with PSIRF some types of patient safety incident must be responded to in a specific way as dictated by national policy or regulation. This can include referral to another body/team, depending on the nature of the event.

The national requirements are set out in the table below:

Details of national requirements
Patient safety incident ttype	Required response	Anticipated improvement route
Deaths thought more likely than not due to problems in care (incidents meeting the learning from deaths criteria for PSII)	PSII	Create local organisational actions and feed these into the quality improvement process
Incidents meeting the Never Events criteria	PSII	Create local organisational actions and feed these into the quality improvement process
Deaths of patients detained under the Mental Health Act (1983) or where the Mental Capacity Act (2005) applies, where there is reason to think that the death may be linked to problems in care.	PSII	Create local organisational actions and feed these into the quality improvement process
Mental health-related homicides	Referred to the NHS England Regional Independent Investigation Team (RIIT) for consideration for an independent PSII Locally- led PSII may be required	Respond to recommendations as required and feed actions into the quality improvement process
Maternity and neonatal incidents meeting Healthcare Safety Investigation Branch (HSIB) criteria or Special Healthcare Authority (SpHA) criteria when in place	Refer to HSIB or SpHA for independent PSII	Respond to recommendations as required and feed actions into the quality improvement process
Child deaths	Refer for Child Death Overview Panel review Locally-led PSII (or other response) may be required alongside the panel review - organisations should liaise with the panel	Respond to recommendations as required and feed actions into the quality improvement process
Deaths of person with learning disabilities	Refer for learning disability mortality review (LeDeR) Locally- led PSII (or other response) may be required alongside the LeDeR - organisations should liaise with this	Respond to recommendations as required and feed actions into the quality improvement process
Safeguarding incidents in which: Babies, children, or young people are on a child protection plan; looked after plan or a victim of wilful neglect or domestic abuse/violence refer to local authority safeguarding lead. Healthcare organisations must contribute towards domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any other safeguarding reviews (and inquiries) as required to do so by the local safeguarding partnership (for children) and local safeguarding adults boards Refer to your local designated professionals for child and adult safeguarding 22. Guide to responding proportionately to patient safety incidents event action required Lead body for the response Adults (over 18 years old) are in receipt of care and support needs from their local authority The incident relates to FGM, prevent (radicalisation to terrorism), modern slavery and human trafficking ordomestic abuse/violence	Refer to local authority afeguarding leads. Healthcare organisations must contribute towards domestic independent inquiries, joint targeted area inspections, child safeguarding practice reviews, domestic homicide reviews and any other safeguarding reviews (and inquiries) as reviews (and inquiries) as required to do so by the local safeguarding partnership (for children) and local safeguarding adults boards	Respond to recommendations as required and feed actions into the quality improvement process
Incidents in NHS screening programmes	Refer to local screening quality assurance service for consideration of locally-led learning response	Respond to recommendations as required and feed actions into the quality improvement process
Deaths in custody (eg police custody, in prison, etc) where health provision is delivered by the NHS	Any death in prison or police custody will be referred (by the relevant organisation) to the Prison and Probation Ombudsman (PPO) or the Independent Office for Police Conduct (IOPC) to carry out the relevant investigations Healthcare organisations must fully support these investigations where required to do so	Respond to recommendations as required and feed actions into the quality improvement process
Domestic homicide	A domestic homicide is identified by the police usually in partnership with the community safety partnership (CSP) with whom the overall responsibility lies for establishing a review of the case CSP 23. Guide to responding proportionately to patient safety incidents event action required lead body for the response Where the CSP considers that the criteria for a domestic homicide review (DHR) are met, it uses local contacts and requests the establishment of a DHR panel The Domestic Violence, Crime and Victims Act 2004 sets out the statutory obligations and requirements of organisations and commissioners of health services in relation to DHRs	Respond to recommendations as required and feed actions into the quality improvement process

Our patient safety incident response plan: local focus

Details of local focus
Patient safety incident type or issue	Planned response	Anticipated improvement route
Deterioration of a patient's mental health condition.	PSIW to make contact with the patient's key worker for mental health support, for example, social prescriber or mental health practitioner.	The PSIW referral form will be updated to include a section for contact details for mental health key worker.
PSIW staff may not understand what is meant by patient safety, rather than safeguarding, and may struggle to identify patient safety issues.	Build PSIW staff knowledge to ensure that they can identify patient safety issues.	Training to be provided to PSIW staff.

Patient safety incident response plan