Please return to:
NHS Litigation Authority Non-Clinical Claims 1st Floor
Napier House High Holborn
London WC1V 6AZ (DX 169 London)
Please complete fully in BLOCK CAPITALS
1. MEMBER DETAILS
Membership Number:
Name and Address:
Telephone Number:
Fax Number:
2. INJURED PARTY DETAILS
Full Name of Injured Party
Address
National Insurance Number
Occupation
Martial Status
Date of Birth
IF THE INJURED PARTY WAS AN EMPLOYEE, PLEASE COMPLETE SECTIONS 3 AND 4. OTHERWISE GO STRAIGHT TO SECTION 4.
3. EMPLOYERS’ LIABILITY CLAIMS
Date of commencement of employment:
For the 13 weeks prior to the accident (or lesser period employed) please state:
i. Gross earnings and Pay Band
ii. Income Tax deducted
iii. NI benefits deducted
iv. Net Earnings
Please state any periods of absence in the 52 weeks prior to the incident, with causes, and whether paid or unpaid (supply details on a separate sheet if necessary)
Nature of injuries (please give as much detail as possible)
If removed to hospital or otherwise medically examined, please provide the name and address of the hospital or doctor
Please state the date on which the employee:
i. Returned to work:
ii If not yet returned, when are they expected back?
4. INCIDENT CIRCUMSTANCES
Date and time:
Location.
Did the incident happen in a PFI developed area?
When was the incident first reported by the Claimant?
Who was it reported to?
Please state what happened.
Does the Claimant’s line manager accept the Claimant’s version of the events as recorded on the Incident Form as being correct?
Were there any witnesses to the incident? If so, please provides names and addresses and state whether they were employed by you?
Please supply any additional information on the following page and sign the ‘Declaration’.
Please do not enter into any correspondence with the injured employee or his/her representatives other than to acknowledge the Letter of Claim.
5. ANY ADDITIONAL INFORMATION
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6. DECLARATION
Name:
………
………
Signature:
………
…..
Status of Signatory:
……….
Date:
………
………...
Please return this form to NHSLA at the address at the top of the first page and make sure that you have:
(a) Signed the ‘Declaration’ and enclosed the Claimant’s Letter of Claim
(b) Where the Claimant is an employee, enclosed all the documents on the NHSLA Disclosure List applicable to the particular type of claim.
Appendix F
Pre-Action Protocol for the Resolution of Clinical Disputes
1. This protocol accompanies the Civil Procedure Rules introduced on 26 April 1999 as part of a package of reforms to improve the way in which civil
litigation was conducted. Lord Woolf had identified numerous problems with the old system, including delays, high costs, unequal access to justice and inappropriate prosecution / defence of cases.
2. The civil Procedure Rules introduced a strict regime for the conduct of civil claims, including clinical negligence. The key elements are openness from an early stage and timeliness in response to claimant’s concerns.
3. When obtaining copies of health records, the requesting party should
complete the Law Society and Department of Health approved standard form providing sufficient information to the healthcare provider that there has been an adverse outcome to treatment. It should also specifically mention which records are required. A signed form of authority for the release of the records should be provided and the copies should be made available within 40 days of the request and at a cost not exceeding those permissible under the Data Protection Act 1998.
4. If, following the receipt of the health records and any relevant expert advice, it is thought that there are grounds for a claim then a Letter of Claim should be sent to the healthcare provider as soon as practicably possible.
5. The Letter of Claim should contain a clear summary of the facts on which the claim is based, including the alleged adverse outcome and the main
allegations of negligence. It should also describe the patient’s injuries, present condition and prognosis. Any financial loss incurred by the patient should also be outlined. The claimant may make an offer to settle at this stage.
6. A chronology of events is helpful, however sufficient information should be provided to enable the healthcare provider to commence their own
investigation and place a value on the claim.
7. The healthcare provider should acknowledge the Letter of Claim within 14 days (21 days for Employment and Public Liability) of receipt and identify who will be dealing with the matter.
8. Within three months of the date of acknowledgement the healthcare provider should provide reasoned response stating whether or not the claim is
admitted, in whole or in part (such admissions are binding and cannot be retracted at a later date). If the claim is denied than an alternative explanation must be given.
9. Any documentation referred to must be disclosed with the response.
10. Where an offer of settlement has been made by the claimant, then a response to that offer should be made. The defendant, supported by reasoning and /or supporting medical advice can make a counter-offer. Proceedings should not be issued within three months of the Letter of Claim, unless there are
limitation problems, or if a reasonable period is agreed by both parties.
Appendix F
WHAT TO DO IN THE EVENT OF A CLAIM
The claim is logged on DATIX as a formal claim or potential and a paper claim file is opened
Governance facilitator
contacts Service manager to obtain relevant
documentation i.e. incident record, health records, sequence of events. Root cause analysis to be
undertaken by the appointed investigating officer
Governance facilitator notifies the NHSLA of claim and seeks advice on what is required
NHSLA will manage the claim unless otherwise specified in the Claims procedure. The relevant documentation is
completed and sent to the nominated claims handler at the NHSLA
Monthly reports are produced on all ongoing claims and potential claims and are discussed at the Risk Management Sub Committee
Staff member becomes aware of a claim or potential claim, they inform line manager.
Line manager informs
Governance facilitator Risk and Claims. Checks are carried out to ensure that claim is the responsibility of MCH, if not a letter is sent to the originator. If so the relevant associate
director is informed
Service managers are to ensure that all staff involved in the case are supported throughout the process and are advised of the outcome of the claim and that lessons learnt are shared and implemented where required Associate director / service
manager / Governance facilitator liaise to ensure that the
appropriate support is provided to interested parties e.g. staff
involved, and the key stages reached are communicated to all relevant parties
GOVERNANCE SCHEDULE
(to be completed in all cases for new and revised policies, procedures, protocols, guidance and patient information leaflets)
1. Title of Document Claims Procedure
2. Purpose of this document and specific risk reduction covered
To detail MCH’s process for handling claims. Litigation risk.
3. Policy/procedure etc. category Risk
4.
6. Committee ratifying this document Quality Committee 7. What other groups/positions have
been consulted with
None
8.
Policy/procedure etc. required by MCH, NHSLA
9. Other organisations covered by this document:
None
10.
Impact on other policies,
procedures, protocols, guidance, patient leaflet
Claims Investigation policy.
11.
Detail staff groups this document applies to:
All staff
12.
Detail any resource/training requirements of document. Detail how and where these will be implemented and by whom:
Root Cause Analysis Training
13. Legal advice obtained (if YES give comments)
YES
NHSLA requirements incorporated
14.
Equality Impact Assessments Completed
(Assessment forms available from HR dept.)
YES
15. Public Involvement NO
16.
Detail governance checks made and name of person responsible for proof reading the document
17. Document sign off by 18. Date signed off
To be retained with the documents master copy by the Governance Office