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 client 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 client, the client has the right to (and must be supported to) access an advocate at any step of this process.
Step 1. Identify the incident and take immediate action
Take any immediate actions required to ensure that everyone is safe and well. This may include:
attending to injuries
undertaking first aid
calling emergency services (000)
moving clients out of harm's way
Managing any immediate risks (e.g. removing potentially dangerous objects from the room)
diffusing any conflicts/arguments.
Calling the HWH after-hours number (1800 717 590)
Incidents that must be recorded and managed include any:
Incident where a client is harmed or could have been harmed while being supported
breach of privacy and confidentiality of an individual's personal information, which has the potential to expose them to harm
incident where another person (e.g. a worker, a member of the general public, or another client being supported) is harmed or could have been harmed by a client while being supported
serious incident that occurred or is alleged to have occurred while a client is being supported.
A serious incident is any incident that involves:
the death of a client while being supported
a serious injury of a worker while on duty or a client while being supported
abuse or neglect of a client while being supported
unlawful sexual or physical contact with, or assault of, a client while being supported or a worker while on duty
sexual misconduct committed against, or in the presence of, a client while being supported, including grooming of the person for sexual activity
unauthorised use of restrictive practices to a client
any discrimination, bullying or harassment of a client while being supported or a worker while on duty
A data breach or breach of privacy and confidentiality poses a serious risk to the individuals affected by the breach.
All serious incidents involving clients (also known as reportable incidents) must be reported to the NDIS complaints commissioner or other appropriate funding body.
Submit an Incident Report which includes the following details about the incident:
A description of the incident
the name and contact details of witnesses (if not you)
a description of the impact on, or harm caused to, the client
a determination of reportable incidents
the initial response to the incident, including immediate actions taken and any actions taken to ensure the health, safety and wellbeing of clients 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 the death of a client while being supported by HWH, the following details are required:
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 (if not you)
the immediate actions taken in response to the incident, including actions taken to ensure the health, safety and wellbeing of any other clients affected and whether the incident has been reported to police or any other body
if known—the time, date and place the incident occurred.
Decision A: Escalation Required
No - (step 4)
Yes - (step 3)
Step 3. Escalate Incident
By completing the HWH Incident Report, all serious incidents will be escalated by the underlying workflow to key HWH managers and the incident response and investigation, if necessary directed accordingly.
Step 4. Respond to incident
To respond to an incident:
We see to the client's immediate needs
Provide first aid or call an ambulance
Provide the client with appropriate support
Notify parents, family or guardian
Report to the police (if necessary)
Record details of the incident (internal incident report)
Provide additional employee training or discipline/remove the employee
Investigate the incident, and review and update relevant client 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).
Step 5. Does the incident require reporting?
Serious incidents that involve the following must be reported to the NDIS commissioner within 24 hours:
the death of a client while being supported
serious injury of a client while being supported
abuse or neglect of a client while being supported
unlawful sexual or physical contact with, or assault of, a client while being supported
sexual misconduct committed against, or in the presence of, a client while being supported, including grooming of the person for sexual activity
the unauthorised use of a restrictive practice relating to a client.
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 besides what is described under the "record incident" policy.
Decision B: Reporting required?
Yes - another process
No - (step 6)
Step 6. Assess the need for investigation
Generally, any incident that needs to be reported to the NDIS Quality and Safeguards Commission or to other funding bodies will require a formal investigation.
Where an incident does not require reporting to the funding body, HWH may decide to conduct an internal investigation regardless to ensure improvements can be made.
Decision C: Investigation Required
No - (step 8)
Yes - (step 7)
Step 7. 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-client 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 managers
an external investigator
The investigation should be carried out while maintaining privacy and confidentiality. The result should be communicated to the client, their family and the advocate (if involved).
The investigation report should include:
A description of the matter investigated
details of the 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.
Refer to the Investigate incident process for more details.
Step 8. Resolve Incident
Resolving an incident involves addressing any underlying patterns or causes of the incident and implementing improvements to the service to minimise the reoccurrence of similar incidents.
Provide appropriate feedback to all parties while considering confidentiality and privacy requirements.
Provide clients, their families, and advocates (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 are notified.
Step 9. 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 responses 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 clients
Improving information security (if the incident was a data breach).
