Reporting of critical incidents and deaths

Use these forms when reporting all critical incidents and deaths

• Critical Incident Reporting Form (DOCX 97 KB) 
• Initial Death Review (IDR) Form (DOCX 95 KB)

Why is DSS collecting this information?

DSS collects and reviews information about the critical incidents and deaths of disabled people receiving support from its contracted service providers to identify and respond to areas of concern, and to help support continuous improvement and better outcomes for disabled people. The information you provide is used to help us do that. 

The information that is reported to DSS will be collected, stored, analysed, and used to inform system improvement, in accordance with the requirements ofPrivacy Act external and other relevant Acts of Law. 

Critical incident notification

Disability providers are required under their contracts with DSS to report all critical incidents to us as soon as practical within 24 hours of the incident.

What is a critical incident?

A critical incident is an event where there is severe or major harm to the person.

• Severe or life-threatening harm, which results in death, severe loss of function and / or requiring lifesaving intervention.
• Major harm which causes major loss of function, serious injury and / or requiring significant intervention.

The types of severe or major harm that DSS requires providers to report as a critical incident are:

1. Death of a disabled person (as a result of an incident)
2. Serious health event or serious injury of a disabled person
3. Self-harm by a disabled person
4. Abuse or assault of a disabled person by a disabled person
5. Abuse or assault of a disabled person by a non-disabled person
6. Abuse or assault of a non-disabled person by a disabled person
7. Restraint or seclusion
8. Unauthorised leave of a disabled person under a court order
9. Disabled person missing
10. Incident related to police involvement, external investigation or media

Download a detailed description of the critical incident categories and definitions (DOCX 138 KB). 

Critical incident notification process

Disability providers are to follow these steps when reporting a critical incident to DSS: 

1. Complete the DSS Critical Incident Reporting Form (DOCX 97 KB)
2. Email your completed form to quality@msd.govt.nz.
   
   If the incident involves someone receiving services under the ID(CC&R) Act external also send the form to IDCCR@health.govt.nz
3. DSS will review the incident and determine if further investigation is required.

If in doubt, please submit a report. Reporting critical incidents is better than under-reporting.  

What does DSS expect disability support providers to do when an incident occurs?

For all incidents, regardless of severity, the provider must act to manage, review and learn from the incident:

• Providers must take action to ensure all people involved are safe and that support is provided that meets the person’s needs and preferences.
• Providers must take action to learn from the incident and reduce future recurrence. Te Tāhū Hauora has a kete of resources and training to support the learning process, as found at Healing, learning and improving from harm policy | Te Tāhū Hauora Health Quality & Safety Commission external.
• Providers will collect information on trends and review them as clusters to inform service and system improvements.
• The provider reports any incident internally as per their organisational incident policy and procedures.

For critical incidents (severe and major harm), the provider also:

• Reports the critical incident to DSS
• Reviews the incident to determine if it is a harm event that meets the Te Tāhū Hauora notification criteria, and if so, reports the harm event to Te Tāhū Hauora in accordance with Healing, learning and improving from harm policy | Te Tāhū Hauora Health Quality & Safety Commission external.

What does DSS do to check that providers are managing incidents well?

• DSS may check provider practice in managing and reducing incidents as part of the routine audit processes.
• DSS will review each critical incident report and may ask the provider for further information about the incident to check that the provider is managing the incident well and implementing changes to reduce future incidents.
• DSS may commission an investigation into the incident if there are significant concerns about the quality and safety of disability supports delivered by a provider.
• DSS collates and analyses critical incident data to inform quality improvement.

Death notification process

Disability providers are to follow these steps when reporting a death to DSS: 

1. Report the death of a disabled person receiving DSS funded support to NASC/EGL site/FCS within 48 hours.
2. Complete a Critical Incident Reporting Form if needed within 24 hours.
3. A critical incident form is required for any death relating to an incident, is unexpected or suspicious, regardless of the type of disability support provided.
4. A critical incident form is not required if the death was due to natural causes or disease progression.
5. Additional requirement for community residential services: 

Disability providers delivering community residential services (including services under the Intellectual Disability Compulsory Care and Rehabilitation Act external) are required under their contracts with DSS to notify DSS of all deaths of disabled people in their service.

Residential providers must therefore also complete an Initial Death Review (IDR) Form (DOCX 95 KB) and email it to DSS within 15 working days.

The form is required for all deaths in residential services, including those due to natural causes.

6. Email your completed Critical Incident Reporting forms and Initial Death Review forms to quality@msd.govt.nz.
7. We will review the death and determine if further investigation is required.

Providers must also determine if they need to notify Te Tāhu Hauora Health Quality and Safety Commission (Te Tāhu Hauora)

Disability providers who are legally or contractually required to comply with Ngā Paerewa Health and Disability Standards are also required to report severe and major harm events to Te Tāhu Hauora. Providers must follow the Te Tāhu Hauora policy Healing, learning and improving from harm policy | Te Tāhū Hauora Health Quality & Safety Commission external.

The goal for this reporting is to potentially reduce future harm by supporting system learnings.

Providers should determine if a critical incident or death meets the Te Tāhu Hauora criteria as per their guidance Severity assessment code (SAC) examples | Te Tāhū Hauora Health Quality & Safety Commission external.

The severity levels for DSS critical incidents aligns with the Te Tāhu Hauora Health Quality and Safety Commission (Te Tāhu Hauora) highest severity definitions. Te Tāhu Hauora uses Severity Assessment Codes (SAC) to define harm severity:

1. SAC 1 Severe or life-threatening harm
2. SAC 2 Major harm
3. SAC 3 Moderate harm
4. SAC 4 Minor harm.

Reporting to DSS and to Te Tāhu Hauora is aligned and has slight differences:

Feedback

We aim to continually improve our data collection and forms to collect better information to support providers and disabled people. If you have any suggestions to improve the process or the forms, please provide your feedback to quality@msd.govt.nz.