Pathways to Better Living – Manage Incident process
This process defines incidents including serious incidents and incidents which are reportable to the NDIS complaints Commissioner.
An incident is broadly defined as:
- Any event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a person, or loss or damage to property
- A near miss which did not cause harm, but had the potential to do so
- A medication error involving a preventable event that may cause or lead to inappropriate medication use or harm to a participant while being supported
- Any event which deviates from standard policy or procedure
- Anything illegal (e.g. assault, sexual misconduct, fraud)
If the incident involves a participant, the participant has the right to (and must be supported to) access an advocate at any step of this process, if they wish.
Identify incident
Incidents that must be recorded and managed include:
- Any incident where a participant is harmed or could have been harmed while being supported
- Any breach of privacy and confidentiality of an individual’s personal information which has the potential to expose them to harm
- Any incident where another person (e.g. a worker, a member of the general public, or another participant being supported) is harmed or could have been harmed by a participant while being supported
- Any serious incident that occurred, or alleged to have occurred, while a participant is being supported
A serious incident is any incident that involves:
- The death of a participant while being supported
- A serious injury of a worker while on duty, or a participant while being supported
- Abuse or neglect of a participant while being supported
- Unlawful sexual or physical contact with, or assault of, a participant while being supported, or a worker while on duty
- Sexual misconduct committed against, or in the presence of, a participant while being supported, including grooming of the person for sexual activity
- Unauthorised use of a restrictive practice in relation to a participant
- Any discrimination, bullying or harassment of a participant while being supported, or a worker while on duty
- A data breach or breach of privacy and confidentiality which poses a serious risk to the individuals affected as a result of the breach
All serious incidents involving participants (also known as reportable incidents) must be reported to the NDIS complaints commissioner
A data breach, where there is a serious risk of harm to the persons affected by the data breach, must be reported to the Office of the Australian Information Commissioner.
Record incident
Record the following details about the incident:
- A description of the incident
- The name and contact details of witnesses
- A description of the impact on, or harm caused to the participant
- Your response to the incident including immediate actions taken and any actions taken to ensure the health, safety and wellbeing of participants affected by the incident and whether the incident has been reported to police or any other body
- If known – the time, date and place at which the incident occurred
- The names and contact details of the persons involved in the incident
If the incident involves a death of a participant while being supported, record the following details:
- A description of the incident including circumstances leading to the death – attach any other relevant documents such as health care plans, palliative care plans
- The name and contact details of witnesses
- The immediate actions taken in response to the incident, including actions taken to ensure the health, safety and wellbeing of any participants affected and whether the incident has been reported to police or any other body
- If known, the time date and place at which the incident occurred
Escalate incident
All serious incidents must be escalated to key management personnel to direct the incident response and to report the incident, if required.
Respond to incident
To respond to an incident:
- See to the participant’s immediate needs
- Provide first aid or call an ambulance
- Provide the participant appropriate support
- Notify parents, family or guardian
- Provide the support worker involved with appropriate support (debriefing/counselling)
- Report to police (if necessary)
- Record details of the incident (internal incident report)
- Provide additional employee training, or discipline/remove the employee
- Investigate incident, review and update relevant participant support plans or risk management plans
Use the internal incident report recorded to add a summary, with the outcome, to the incidents register (internal document for recording incidents)
Does the incident need to be reported?
Serious incidents that involve the following must be reported to the NDIS commissioner within 24 hours:
- The death of a participant while being supported
- Serious injury of a participant while being supported
- Abuse or neglect of a participant while being supported
- Unlawful sexual or physical contact with, or assault of, a participant while being supported
- Sexual misconduct committed against, or in the presence of, a participant while being supported, including grooming of the person for sexual activity
- The unauthorised use of a restrictive practice relating to the participant
Any other type of serious incident, not listed above, must be reported to the NDIS commissioner within five business days.
Note: The NDIS commissioner may request other information in addition to what is described under record incident.
Report incident
Submit an incident report to the NDIS Commission along with any additional documents and details related, such as participant lifestyle plans, management plans, and any other details related to the incident/complaint and resolution.
The NDIS commissioner may in turn refer the incident on to:
- Police
- Worker screening units
- Consumer Affairs agencies
- Other regulatory bodies
If the incident is a data breach, reporting it to the OAIC may be required if it is a notifiable data breach.
Assess the need for investigation
Generally, any incident that needs to be reported to the NDIS Quality and Safeguards Commission will require a formal investigation.
Where an incident does not require reporting to the NDIS commission, we may decide to conduct an internal investigation regardless to ensure improvements can be made.
Unauthorised use of restrictive practice
Did the incident involve an unplanned or unauthorised use of a restrictive practice in relation to a participant?
Investigate incident
An investigation involves the planned and systematic gathering and analysis of all relevant facts through obtaining evidence by interviewing witnesses, examining documentation, skilled observation and obtaining expert opinion. An investigation into alleged worker to participant incidents or unexplained injuries must be person-centred.
Depending on the severity of the incident, the investigation should be carried out by an investigator, preferably someone impartial who could be:
- A senior worker
- Key management personnel
- An external investigator
The investigation should be carried out maintaining privacy and confidentiality. The result should be communicated with the participant, their family and advocate (if involved).
The investigation report should include:
- A description of the matter investigated
- Details of allegations
- Details about the investigation, e.g. witnesses interviewed
- Documentary evidence considered
- Summary of the key evidence
- Conclusions and findings based on the salient evidence
Resolve incident
Resolving an incident involves addressing any underlying patterns or causes of the incident and implementing improvements to the service to minimise reoccurrence of similar incidents.
Provide appropriate feedback to all parties involved while keeping in mind confidentiality and privacy requirements.
Provide participants, their family, and advocate (if involved), opportunities to provide feedback on the response, investigation (if a formal investigation was carried out) and resolution.
If the incident is a notifiable data breach, urgent remedial action is required and affected persons notified.
Develop interim behaviour support plan
Work with a behaviour support practitioner to develop an interim behaviour support plan for the participant involved in the incident.
Review incident
Review the incident by examining the incident from start to finish, analysing the investigation report (if a formal investigation was carried out), and reviewing response and feedback.
Improvements or corrections can now be made to ensure a similar incident does not occur again. These may include:
- Additional training of workers
- Better supervision of workers
- Changes to routines or rosters within a service
- Reviewing and refining support plans for certain participants
- Improving information security (if the incident was a data breach)
