Incident Report - Mind CHWF

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Date of the incident

Time of the incident

Example: 14:55

Reported By:(Required)

Logged By:(Required)

Client's name

Full Names of Parties Involved

All parties involved including full name of service user(s) and staff and others where known

Location of Incident

Other location

Please specify the location when incident happned

Project/Service this incident relates to

Service Other

Incident Classification

Serious crime or violence to service users, staff, visitors or member of the public

Serious threats to service users, staff, visitors or member of the public

Suicide or attempted suicide

Death or serious injury of service user, staff, visitor or member of the public

Incident that led to a serious disruption of services including fire, flood, power failure

Serious damage to property

Data Incident

Health and Safety Incident

Other (please explain in description)

Description of Incident

Clients assigned staff (external)

Details of any care coordinator/social worker from Hackney or other Local Authority, NHS Mental Health Trust or similar body such as London Probation.

Immediate Action Taken

Brief description of action already taken

Preventative Action Taken

What have you done to prevent this happening again?

Further Action Required

Details of any further action required after the incident is logged.

Involvement of Emergency Services?