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LineIn Operations

Significant Event Investigation Report

Site

PSC

Date of event

Report date

Reference

Practice & Event Details

Practice name
PCN (if applicable)
Date of event
Date reported
Report prepared by
Call handler
Call type
How identified

STEP 1 Initial Report — Ops Team Complete within 2 hours of the event being identified

Description of event

What to write: A factual account of what happened on the call. Include: what the patient requested, what the PSC did or said, the outcome of the call, and how it was identified as a significant event. Do not include opinions — facts only.
Example: "Patient called requesting an urgent GP callback for chest pain. PSC [name] advised the patient to call back the following morning and disconnected the call without arranging a callback or escalating. Identified by patient complaint received same day."

Consequence of event

What to write: What actually happened as a result of this call. Did the patient receive delayed care? Was there potential for harm? What was the immediate impact on the patient and the practice?
Example: "Patient did not receive timely medical assessment. Patient subsequently called 999 and was taken to A&E. Practice was contacted by the patient's family and lodged a formal complaint."

Risk assessment

What to write: Rate the clinical and patient safety risk (Low / Medium / High / Critical) and explain why. Consider: potential for harm, likelihood of recurrence, vulnerability of patient.
Example: "High risk. Patient presented with acute cardiac symptoms. Failure to escalate a patient describing chest pain represents a critical patient safety failure. Risk of harm was significant."

STEP 2 Investigation — Team Leader Complete within 48 hours — speak with the PSC directly

Investigation

What to write: Document your full investigation. Include: when and how you spoke with the PSC, what they said about the call, their understanding of the protocol, what training records show, and whether this is an isolated incident or a pattern.
Example: "Meeting held with [PSC name] on [date] via Teams. PSC confirmed they did not recognise chest pain as a red flag symptom. Review of training records confirms red flag symptom training was completed in [month]. PSC unable to explain the protocol gap. Call recording reviewed — patient clearly stated 'chest pain' twice. No previous SE record for this PSC. Incident appears to be a one-off but reflects a gap in application of training."

STEP 3 Actions & Learning — Training Team / Ops Manager Complete within 5 working days

Actions taken

What to write: List every action taken in response to this event. Include who did what, and on what date. Actions may include: formal feedback session, refresher training, workbook update, protocol review, practice notification, escalation to HR.
Example: "1. Formal feedback session held with PSC [name] by TL [name] on [date] — red flag protocol reviewed in full. 2. Targeted refresher training on red flag symptoms delivered by Training Team on [date]. 3. Practice Manager at Hucknall Road contacted by Ops Manager on [date] via Teams — apology issued and incident explained. 4. Workbook updated to include additional red flag symptom examples — effective [date]."

Learning and service improvement

What to write: What has the team or organisation learned from this? What has changed as a result? Include any systemic improvements, monitoring that will be put in place, or wider team communications.
Example: "Red flag symptom protocol has been reinforced across all PSCs via group training session on [date]. Spot check criteria updated to specifically include red flag symptom handling as a review point. All new starters will receive targeted red flag training as part of induction from [date]. Monitoring of red flag call handling to be included in quarterly QA review."

Training identified

What to write: Was a training need identified from this event? If so, what training, for whom, and who will deliver it. Write "None identified" if no training need was found.

Impact assessment

Patient impact
Practice impact

Root cause analysis

Primary root cause
Contributing factors

Quality assurance outcome

Audit completed
Outcome
Key findings

Client communication

Date practice informed
Method
Delay acknowledged

Supporting documents

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Report sign-off

Completed by
Date
Status
Clinical Director review (if clinical risk / patient harm)