Queensland Health guidelines

Serious Incident Response Scheme (SIRS) for Transition Care Programme

Guideline number: QH-GDL-981

Effective date: 2 July 2024

Review date: 2 July 2027

Supersedes: New document

On this page:

Purpose
Scope
Requirements
Legislation
Supporting Documents
Definitions
Version control

1. Purpose

This guideline outlines the processes for reporting under the Serious Incident Response Scheme (SIRS) for Queensland Health staff to meet the requirements of the Aged Care Act 1997 (the Act) legislation.

Detailed information on SIRS reporting can be found on the Aged Care Quality and Safety Commission website, including the SIRs Guidelines for providers of home services and the SIRS Guidelines for residential aged care providers.

2. Scope

This guideline applies to all Queensland Health staff providing aged care services through the Transitional Care Programme (TCP) in community and residential settings.

3. Requirements

3.1 Overview

3.1.1. The SIRS aims to prevent the abuse and neglect of older Australians receiving aged care services. Aged care providers have responsibility to prevent, manage, respond effectively to and minimise risk of abuse and neglect in connection with the care they provide.

3.1.2. The SIRS establishes responsibilities for all Commonwealth-funded providers of aged care, including approved providers under the Aged Care Act to:

prevent and manage incidents, focusing on the safety, health and wellbeing of consumers
use incident data to drive quality improvement
notify reportable incidents to the Aged Care Quality and Safety Commission (the Commission).

3.1.3. The Aged Care and other Legislation Amendment Bill (Royal Commission Response) Act 2022 responded to 17 recommendations of the Royal Commission and extended SIRS to aged care services, including in-home care.

3.1.4. The SIRS complements the Charter of Aged Care Rights (the Charter), the Code of Conduct for Aged Care (the Code of Conduct), the Aged Care Quality Standards (the Quality Standards) and open disclosure requirements.

3.1.5. The Commission has the power to take regulatory actions where appropriate to address non-compliance with provider responsibilities and SIRS obligations.

3.1.6. Regulatory actions may include imposing sanctions under Part 7B of the Quality and Safety Commission Act 2018 on approved providers who do not meet their responsibilities under the Aged Care Act.

3.1.7 Details of the range of regulatory powers and actions can be found in the Commission’s SIRS Guidelines for providers of home services.

3. 3.2 Incident management and notification

3.2.1. In addition to management and prevention responsibilities for all incidents set out in the Quality Standards (Standard 8), the SIRS introduces additional incident management and notification requirements for a subset of incident types in relation to:

3.2.1.1. Incident management and prevention, including requirements for:

responding to, assessing and managing incidents
notifying other persons or bodies (including the police) of certain incidents
continuously improving incident management and prevention
implementing and maintaining an incident management system, including:
- establishing procedures for identifying, managing, and resolving incidents
- documenting and record keeping in relation to incidents
- supporting staff to use and comply with the incident management system.

3.2.1.2. Notifying the Commission of reportable incidents, including requirements for:

ensuring staff escalate and report reportable incidents within the organisation
notifying the Commission of reportable incidents within required timeframes (section 3.6)
including specific information about a reportable incident in the notification.

3 3.3 Reportable incidents

3.3.1. Section 54-3 of the Aged Care Act defines a reportable incident and outlines the eight types of reportable incidents that are required to be notified to the Commission under the SIRS.

3.3.2. A reportable incident is:

an incident that has occurred, or is alleged or suspected of having occurred, in connection with the provision of care to a consumer
the incident has caused harm, or could reasonably have been expected to have caused harm, to a consumer, and
the incident is one of the following types of incidents:

Reportable incident type	Definition
Unreasonable use of force	Includes conduct ranging from a deliberate and violent physical attack to use of unwarranted physical force. Includes conduct such as shoving, pushing, hitting, punching, kicking or rough handling of a consumer.
Unlawful sexual contact or inappropriate sexual conduct	Includes contact or conduct inflicted by a person who is a staff member of the provider or a person who provides care or services for the provider and is providing such care and services at the time of the incident (e.g. while volunteering): any conduct or contact of a sexual nature inflicted on the consumer, including but not limited to sexual assault, an act of indecency or the taking and/or sharing of an intimate image of the consumer any touching of the consumer’s genital area, anal area or breast in circumstances where this is not necessary to provide care or services to the consumer any non-consensual contact or conduct of a sexual nature, including but not limited to sexual assault, an act of indecency or the taking and/or sharing of an intimate image of the consumer engaging in conduct relating to the consumer with the intention of making it easier to procure the consumer to engage in sexual contact or conduct.
Psychological or emotional abuse	Includes conduct that has caused, or that could reasonably have been expected to have caused, psychological or emotional distress to a consumer, including actions such as: taunting, bullying, harassment or intimidation threats of maltreatment humiliation unreasonable refusal to interact with the consumer or acknowledge the consumer’s presence unreasonable restriction of the consumer’s ability to engage socially or otherwise interact with people repetitive conduct or contact which does not constitute unreasonable use of force but the repetition of which has caused, or could reasonably have been expected to have caused, the consumer psychological or emotional distress.
Unexpected death	Where the death is the result of care or services provided by the provider or a failure by the provider to provide care and services. Providers are required to notify the Commission of any death where the provider, including staff and health professionals engaged by the provider: made a mistake resulting in death did not deliver care and services in line with a consumer’s assessed care needs, resulting in death provided care and services that were poorly managed or not in line with best practice, resulting in death.
Stealing or financial coercion	Includes: stealing from a consumer by a staff member of the provider conduct by a staff member of the provider that: is coercive or deceptive in relation to the consumer’s financial affairs unreasonably controls the financial affairs of the consumer.
Neglect	Includes: a breach of the duty of care owed by the provider, or a staff member of the provider, to the consumer a gross breach of professional standards by a staff member of the provider in providing care or services to the consumer. Does not include: the incident results from a choice made by the consumer about the care or services provided to them, or how the care or services are to be provided, and before the incident occurred, is alleged to have occurred, or is suspected of having occurred, the choice had been communicated by the consumer to the provider, the provider had communicated any risks associated with that choice to ensure the consumer was informed, and the provider had recorded the discussion and the choice in writing.
Inappropriate use of restrictive practices	Includes any practice or intervention that has the effect of restricting the rights or freedom of movement of a consumer. Whether the use of a restrictive practice is a reportable incident (i.e., it is an inappropriate use of restrictive practice) depends on the circumstances in which it is used, and whether these are consistent with requirements as described in the Quality of Care Principles.
Missing consumers	Includes a consumer going missing in the course of a services provider delivering care and services to the consumer and there are reasonable grounds to report that fact to police. Includes situations where a provider has the consumer in their physical care immediately prior to their absence. For example: a staff member has taken a consumer to the shops and the consumer has gone missing during the outing a consumer goes missing while in overnight respite, receiving care at a day therapy centre, receiving transport services or on a scheduled outing with the provider a consumer goes missing while a staff member is delivering care and services in the consumer’s home and there is reason for concern (e.g. the consumer could be harmed if they were wandering alone).

3.3.3. For home services, this may include any incidents:

resulting from the action (or inaction) of a staff member of the provider. This includes subcontracted individuals or organisations, those managing care coordination, administration, etc. and volunteers
that occur while care and services are being delivered to a consumer (e.g., where the consumer is participating in an activity outside of the consumer’s home organised by the provider and is bullied or harassed by another consumer).

3.3.4. The SIRS decision support tool provides general guidance to help decide whether an incident should be notified to the Commission.

3.4 Non-reportable incidents

3.4.1. An incident that is not one of the eight reportable incident types does not need to be reported under the SIRS. However, the incident may still need to be reported via local Hospital and Health Services procedures such as RiskMan.

3.5 Priority 1 reportable incidents

3.5.1. A Priority 1 reportable incident is any reportable incident:

that caused, or could reasonably have been expected to have caused, a consumer physical or psychological injury or discomfort that requires medical or psychological treatment to resolve
where there are reasonable grounds to report the incident to police
involving unlawful sexual contact or inappropriate sexual conduct inflicted on a consumer
that is an unexpected death of a consumer
where a consumer goes missing in the course of provision of home services.

3.5.2. Reportable incidents will be Priority 1 regardless of whether:

the impact on the consumer is temporary or permanent
the medical or psychological treatment is provided at the service or elsewhere.

3.5.3. A Priority 1 reportable incident includes but is not limited to:

consumer distress requiring emotional support or counselling
cuts, abrasions, burns, fractures, or other physical injury to a resident requiring assessment and/or treatment by a nurse, doctor, or allied health professional
bruising, including large individual bruises or several small bruises over the consumer
head or brain injuries which might be indicated by concussion or loss of consciousness
injury or impairment requiring the consumer’s attendance at or admission to a hospital
the death of a consumer.

3.6 Priority 2 reportable incidents

3.6.1. A Priority 2 reportable incident includes any reportable incident that does not meet the Priority 1 criteria as outlined above.

3.6.2. Examples of Priority 2 reportable incidents may include incidents in which:

the consumer is momentarily shaken or upset
the consumer experiences temporary redness or marks that do not bruise (or could not reasonably have been expected to cause an injury)
medical or psychological treatment for the consumer is not (or could not reasonably have been expected to be) required.

3.7 Reporting timeframes

3.7.1. Priority 1 incidents must be reported to the Commission within 24 hours of becoming aware of the incident.

3.7.2. Priority 2 incidents must be reported to the Commission within 30 days of becoming aware of the incident. This includes all other reportable incidents that do not meet the criteria for a ‘Priority 1’ incident.

3.8 Reporting process

3.8.1. TCP providers are responsible for following the SIRS process for all reportable incidents, including when services are brokered to other agencies.

3.8.2. All reportable incidents are to be notified to the Commission by providers via the My Aged Care Service and Support portal.

3.8.3. An incident must also be reported to the police when there are reasonable grounds to do so and reported to other relevant authorities when required.

3.8.4. Incident notifications need to be sufficiently detailed and include but are not limited to:

the context of the reportable incident
actions undertaken to ensure the safety, health and wellbeing of the consumer(s) involved
determine the level of harm and/or discomfort caused (or that could reasonably have been expected to have caused) to the consumer(s) involved
actions taken to manage the incident and minimise the risk of reoccurrence
demonstrate the effectiveness of the provider’s incident management system to manage, prevent, assess, report and resolve incidents and continuous improvement.

3.8.5. Once completed, incident notifications are to be forwarded to the Queensland Department of Health via strategicpolicy@health.qld.gov.au.

4. Legislation

Aged Care Act 1997
User Rights Principles 2014
Quality of Care Principles 2014
Accountability Principles 2014
Aged Care Quality and Safety Commission Act 2018
Human Rights Act 2019
Hospital and Health Boards Act 2011
The Aged Care and other Legislation Amendment Bill (Royal Commission Response) Act 2022

5. Supporting documents

Charter of Aged Care Rights
Aged Care Quality Standards
Aged Care Open Disclosure Framework and Guidance
The Code of Conduct for Aged Care
Aged Care Quality and Safety Commission Serious Incident Response Scheme: Guidelines for providers of home services

6. Definitions

Term	Definition
Aged Care Act 1997 (the Act)	The main law that sets out rules for government-funded aged care. The Act outlines the obligations and responsibilities that aged care providers must follow to receive subsidies from the Australian Government.
Aged Care Quality and Safety Commission (Commission)	The national regulator of aged care services and the primary point of contact for clients/patients and providers in relation to quality and safety in aged care in Australia.
Approved provider	As defined in the Aged Care Quality and Safety Commission Act 2018 (the Commission Act), a person or body: Who has been approved as a provider of aged care or taken to be an approved provider under the Commission Act; and Whose approval is in effect
Consumer	A person who is receiving in-home services care.
Home services	Commonwealth-funded aged care services delivered in the home or community.
Continuous improvement	A systematic, ongoing effort by an organisation to raise its performance in achieving outcomes for consumers under the Aged Care Quality Standards.
Incident	Any act, omission, event or circumstance that has occurred, is alleged to have occurred, or is suspected to have occurred in connection with the provision of care and services to a consumer and has (or could reasonably be expected to have) caused harm to a consumer or another person (such as a staff member or visitor to the service).
Incident management system (IMS)	Any system that helps an organisation to prevent, identify, respond to and manage incidents that occur during the course of delivering care and services to consumers. An IMS should be used in relation to all incidents, that are known, suspected or alleged to have occurred in connection with the delivery of care and services.
Provider	A provider approved under the Aged Care Act (or funded through funding agreements) to provide Commonwealth-funded aged care services delivered in the home or community.
Staff	An individual who is employed, hired, retained or contracted by a provider (whether directly or through an employment or recruiting agency) to provide care or other services. Accountability Principles 2014 extends this definition to volunteers of providers of in-home services where appropriate.

7. Version control

Version	Date	Comments
V1	1 March 2024	Guideline developed

Last updated: 2 July 2024