Report a Clinical Incident
Name:
*
First Name
Last Name
Designation:
*
Email:
*
example@example.com
Service name:
*
Date of incident
*
-
Day
-
Month
Year
Date
Time of incident:
*
Name of Florence care professional(s) involved:
*
Type of incident:
*
Poor professional conduct
Medication error
Right to work
Manual Handling
Other
If other, please provide the category:
*
Has this been reported to an external body?
*
Yes
No
Which external body(s)?
*
Impact of incident:
*
Injury / Harm caused
No injury / No harm caused
Near miss
Death of service user
Actions for Florence:
*
Investigate and share outcome
Request for statement only
No action, notification purposes only
No immediate action, wait for external body investigation
Please provide your statement of events:
*
For us to be able to investigate fully, please upload files to support statement (witness statement, photographs, MAR chart etc.)
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Please confirm you have provided us with all the relevant information and any evidence:
*
Confirmed
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