Incident Record Form To be completed by Lydian managers for any incident/accident/complaint or notifiable event. A copy of this form will be sent to the person reporting the event and to the registered manager. Type of Report:*IncidentMedication ErrorPersonal accident or any accidentComplaintNotifiable EventNear MissMissed or Late Domiciliary CallsSelect from drop down list the type of report you are making.Date Report Completed:* Day Month Year Time* : Hours Minutes Report taken From:*This is the staff member who reported the incident/event to you to record. First Last Name of person making the report:*This is your details as the person completing the form. First Last Contact Details of person making the report:* Email Address - You will receive a copy of the completed form.Manager for area incident/event occured:*Carol SavageRachel DeeryWas a Service User Involved?YesNoService User Name* First Name Last Name Service User Address* Street Address Address Line 2 City Postcode Gender: Male Female Date Of Birth: Day Month Year Contact Number:*Was a Member of Lydian Staff Involved?*YesNoStaff Members Name:* First Name Last Name Was more than one member of Lydian Staff Involved?*YesNoStaff Members Name:* First Name Last Name Date of Incident:* Day Month Year Time Of Incident:* : Hours Minutes Where and When did the incident occur?*Primary Location e.g. service users home (including Address & Postcode if appropriate)Exact location:*Actual location of incident e.g. kitchen, bedroom etc.Outline apparent circumstances of the incident (give brief factual objective details)*Outline what happened together with any relevant circumstances. Where applicable, what was the person doing? Were there any contributory factors?Outline the complaint as received*Outline the complaint as received.Was the incident caused as a result of behaviours of concern related to a specific illness or diagnosis?*YesNoIf yes, is this documented in their Care Plan?*YesNoDid the person/individual suffer an injury as a result of the incident?*YesNoWhich part of the body was affected? e.g. back, left shoulder, right eye, neck, trunk etc.*Identify all areas affected What nature of injury was sustained? e.g. abrasion, bruising, laceration, sprain/strain, fracture etc.*If more than one body part is identified above, please identify which injury relates to which body part What was the apparent cause of injury? e.g. slip, trip, fall, physical assault etc.*Type of incident Was any equipment involved?*Only choose ‘Yes’ if the equipment involved was linked to the cause of the incident.YesNoDetail Equipment involved:*For example Hoist. Where relevant, have you reported to NIAC (NI Adverse Incident Centre)*YesNoWas any property involved? (Home or personal possessions)?*Only choose ‘Yes’ if the property involved was linked to the cause of the incident.YesNoDetail Property involved:*For example House Key. Did the incident involve Medication?*YesNoPlease record the name(s) and dose/quantity of each medication involved. If the medication incident occurred due to a Pharmacy related incident, please also give details of the relevant Pharmacy:Outline any remedial or other action taken following the incident (give brief factual details)*What action was taken at the time the incident was discovered.Persons notified including designation / relationship to Service User*Name, designation and contact details of any witnesses*Witnesses are only those individuals who saw the incident occurring – not who came across the incident after the event.