EA-4.02 · Accident, Incident, Near-Miss & Safeguarding Report

1. Start the Record

Person affected

Preferred name

Service / provider

Completed by

Role

Date record started

What are you recording?

Choose all that apply. The form will open the relevant sections.

Date of event

Time of event

Where did it happen?

Was anyone in immediate danger?

2. What Happened?

Describe what happened

Use clear facts. Include what happened before, during and immediately after the event where relevant.

What was seen, heard or found?

What did the person say about what happened?

Were other people involved?

What happened immediately before the event, if known?

3. Injury / Harm

Type of injury / harm

Part of body affected

How serious did it appear?

Was first aid given?

Describe the injury or harm

First aid / immediate treatment given

Was medical help sought?

Medical advice / outcome

Body Map Notes

Body map / injury location notes

Were photographs taken in line with policy and consent / lawful authority?

Where are any photographs securely stored?

4. Safeguarding / Adult Protection Concern

Protect first. If there is an immediate risk of harm, take urgent protective action and contact the appropriate emergency or statutory service.

What is the safeguarding concern?

Type of possible harm

Who may have caused or contributed to the harm?

What immediate action was taken to protect the person?

What did the person say or communicate?

Was an Adult Support and Protection referral made?

Date / time referred

Local authority / contact

Referral reference / outcome known so far

If referral was delayed or not made, record the reason

Do not carry out your own investigation unless this is part of your authorised role. Preserve relevant evidence, record facts, and follow local Adult Support and Protection procedures.

5. Medication-Related Event

What happened?

Medication involved

What immediate action was taken?

Was professional advice sought?

Advice received / outcome

Update EA-4.03 Medication Management Record where the event changes medication support, controls or monitoring.

6. Witness Information

Record factual accounts. Where a separate signed statement is needed, store it securely and note its location.

Name	Contact / role	What they saw or heard

Location of any separate witness statements

7. Immediate Action

What was done immediately?

What was done to make the situation safe?

Did support arrangements need to change straight away?

Was the person informed and involved in decisions about what happened next?

Person's comments / wishes

8. Notifications & Reporting

Do not assume every event has the same reporting route. Check current Care Inspectorate, Adult Support and Protection, employer, health and safety, commissioning and local procedures.

Person / body	Needed?	Date / time	Reference / notes
Manager / on-call
Family / representative (where appropriate)
Social worker / care manager
Care Inspectorate
Local authority Adult Support & Protection
Police
Health & Safety / other external body

Who decided which notifications were required?

Reason for the notification decision

Any other notification / reporting requirement

9. Manager Review & Learning

What appears to have contributed to the event?

Could anything reasonably have prevented or reduced the event?

Is this linked to a previous event or pattern?

Pattern / previous event details

What has been learned?

Actions

Action	Who?	Due date	Complete

Records to update

EA-4.01 Risk, Safety & Emergency Plan

EA-4.03 Medication Management Record

EA-4.04 Health & Wellbeing Record

EA-4.05 Fire Safety Management Record

EA-5.01 Property, Safety & Maintenance Record

EA-6.01 Person-Centred Support Plan

EA-6.02 Support Review & Outcomes Record

EA-9.01 Service Event Register

EA-9.04 Quality, Compliance & Improvement Record

10. Sign-Off

Person's comments, where appropriate

Person's name

Date

Person's signature

Upload signature

Manager / reviewer name

Role

Review date

Event closed?

Manager / reviewer signature

Upload signature

Closure comments / outstanding actions