Form (1a) - Statutory Notification of Events
(Adult Services)
(Please complete all relevant sections)
Part 1: Service Details
Establishment/Agency Name:
(i.e. Nursing Home, Residential Care Home,
Day Care Setting, Nursing Agency, Domiciliary
Care Agency, Adult Placement Agency,
Independent Hospital, Independent Clinic)
(please refer to your current certificate of
registration)
Establishment/Agency Type:
RQIA Registration Number:
Part 2: Details of Service User affected
Unique Identifier
Year of Birth
(Please Do Not Use Name)
(yyyy)
More than one Service
user affected?
Gender
Date of Admission
(male/female)
(dd/mm/yy)
(if more than 1 service user is affected please tick box and list the details of
remaining individuals as above in Part 4 of this form)
Part 3: Information about the Event/Death
Timing of Event/Death:
Date (dd/mm/yy)
Time (hh:mm)
Please select one of the following:
(G1) Death
Please provide details:
Certified cause: (if known)
G1.2 Death unexpected:
(G2) Serious Injury
Please specify injury (if applicable):
G2.1 Fracture (Hip)
G2.2 Fracture (Other)
G2.3 Head Injury
(G3) Accident
(G4) Serious Illness
(G5) Outbreak of Infectious Disease
(G6) Allegation of Misconduct
Please specify (select one main type only):
G6.1 Physical
G6.4 Financial/ Material
G6.7 Discriminatory
G6.2 Sexual
G6.5 Neglect/Acts of Omission
G6.8 Damage to property
G6.3 Psychological/
Emotional
G6.6 Institutional
G6.9 Misuse of drugs
(G7) Incident involving the police
(G8) Any other event adversely affecting service user
G8.1 Medication Incident
G8.3 Suicide/Self Harm
G8.2 Behavioural Issue
G8.4 Estates Issue
Please specify (if applicable):
(A1) Theft or Burglary
(A2) Unexplained absence
RQIA_NotifiableEvents_Form1a_ Jan2011
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Any other organisations and/or individuals informed:
Name of organisation/individual
Date (dd/mm/yy)
Police Service of Northern Ireland (PSNI)
Care manager/key worker (HSC Trust)
Independent Safeguarding Authority (ISA)
Northern Ireland Social Care Council (NISCC)
Nursing and Midwifery Council (NMC)
Others:
(e.g.
NIAIC)
Part 4 Concise description of surrounding circumstances
Details of the
event/death
(where
appropriate:
incident details,
duration, people
involved,
behaviors
displayed,
condition of those
involved)
Any
immediate
action taken
following the
event
(where
appropriate)
Any action
taken to
prevent
recurrence
(where
appropriate)
Has associated risk assessment and care plan been fully updated?
(Yes, No, N/A)
Part 5: Form Completed by:
Name
Job Role
Date (dd/mm/yy)
Please return form by email to: [email protected]
RQIA_NotifiableEvents_Form1a_ Jan2011
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