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St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Adverse Event Report & Investigation Form


Introduction
The purpose of this form is to record all adverse events.
Please read this front page BEFORE starting to complete any part of the form.
The term accident is used where injury or ill health occurs. The term incident includes near-misses
and undesired circumstances, where there is the potential for injury.
Part 1 : Overview
should be filled out immediately by the manager or supervisor for the work activity
involved and delivered without delay to the Parish Administrator or Incumbent.
Part 2 : Initial Assessment
should be completed by a person responsible for health and safety.
Part 3 : Investigation Information Gathering
should be completed, where appropriate, by an investigation team.
Part 4 : The Risk Control Action Plan
should be completed by the same investigating team, together with managers who
have the authority to take decisions.

When completing Parts 2, 3 and 4 refer to the booklet


Investigating Accidents and Incidents
for a step by step guide to health and safety investigations.
Click for

a full version of
the chapter
the chapter
the chapter
the chapter
the chapter

Investigating Accidents and Incidents inc. worked examples


Reducing Risks and Protecting People
Understanding the Language of Investigation
The Causes of Adverse Events
Why Investigate?
A Step by Step Guide to Health & Safety Investigations

Dan Tyndall
August 2015

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Part 1 : Overview
Reported by

PASTORAL
CONCERN

Date/time of adverse event

ILL
HEALTH

INCIDENT

ACCIDENT

near miss or undesired circumstance

where injury to a person occurred

Brief details (What, where, when, who and emergency measures taken)

Signature of person reporting event

Forwarded to

Date
Time

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Part 2 : Initial Assessment


(to be carried out by a person responsible for health and safety)

Reference Number
Each adverse event is to be assigned a sequential Reference Number (YYYY/nn). This reference
number is to be added to the footer of the electronic version of this form and written onto every
page of any version printed prior to a number being assigned. Parish Administrator and Health &
Safety Officer will be able to supply the correct next reference number.
What Ref No. has been assigned

Who assigned it

Has Ref No. been added to Footer

Y/N

Who added it

Has Ref No. been written onto printed copies

Y/N

Who wrote it

Type of event

Actual / potential for harm

Pastoral Concern

Fatal or major

Ill health

Serious

Incident: Near-miss

Minor

Incident: Undesired circumstance

Little or none

Accident

Damage only (e.g. property, environment, etc.)

Accidents need to be recorded in one of our Accident Books


Date recorded:
RIDDOR reportable?

CHURCH

OFFICE

Reference No:
Yes No

Date/time reported:

Further investigation required and, if so, at what level


click for section "The Decision to Investigate" which outlines the process to use
No further
investigation

Minimal
Level

Low
Level

For investigation by

Initial assessment carried out by


Date
Signature(s)

Reference Number:

YYYY/nn

Medium
Level

High
Level

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Part 3 : Investigation Information Gathering


click for chapter "Step by Step Guide to Health & Safety Investigations"
(to be carried out by an investigation team)

Where and when did the adverse event happen?

Who was injured/suffered ill health or was otherwise involved with the adverse event?

How did the adverse event happen? (Note any equipment involved.)

What activities were being carried out at the time?

Was there anything unusual or different about the working conditions?

Were there adequate safe working procedures and were they followed?

What injuries or ill health effects, if any, were caused?

If there was an injury, how did it occur and what caused it?

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Was the risk known? If so, why wasnt it controlled? If not, why not?

10 Did the organisation and arrangement of the work influence the adverse event?

11 Was maintenance and cleaning sufficient? If not, explain why not.

12 Were the people involved competent and suitable?

13 Did the workplace layout influence the adverse event?

14 Did the nature or shape of the materials influence the adverse event?

15 Did difficulties using the plant and equipment influence the adverse event?

16 Was the safety equipment sufficient?

17 Did other conditions influence the adverse event?

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Analysis and further action


Please refer to the following two sections of Investigating Accidents and Incidents
click for section "Analysing the Information"
click for section "Identifying Suitable Risk Control Measures"
18 ANALYSIS What were the immediate, underlying and root causes?

19 RISK CONTROLS What risk control measures are needed/recommended?


1
2
3
4
5
6

20 Do similar risks exist elsewhere? If so, what and where?

21 Have similar adverse events happened before? Give details

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

Part 4 : The Risk Control Action Plan


Please refer to the following section of Investigating Accidents and Incidents
click for section "The Action Plan and Its Consequences"
(to be carried out by the same investigating team, together with managers who have
the authority to take decisions)

22 Which risk control measures should be implemented in the long and short term?
Control measure

Completion date

Person responsible

23 Which risk assessments and safe working procedures need to be reviewed and updated?
Risk Assessment or Safe Working Procedure

Completion date

Person responsible

24 Have the details of the adverse event and the investigation findings been recorded and
analysed? Are there any trends or common causes which suggest the need for further
investigation? What did the adverse event cost?

Reference Number:

YYYY/nn

St Mary Redcliffe Adverse Event

Version dated 29-Sep-15

25 Signed on behalf of the investigation team


Name

Signature

26 Members of the investigation team


Name

Position

27 The findings of this investigation need to be communicated to the following


managers, union and employee safety representatives
Person needing to know

Persons signature & date they were informed

Reference Number:

YYYY/nn

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