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Even in the best-run organisations, things can go wrong. Be it an infringement of privacy, personal injury or death, the implications for registered social landlords can be substantial.

According to the Health & Safety Executive, in the 12-month period of 2000/01 there were 445 fatal injuries reported by industry to the enforcing authorities.

The Housing Corporation's Guide to Responding to Allegations, published in April 2002, concludes that problems arise if internal investigations have not been thorough enough or have been carried out without consideration of the wider implications.

Although the guide focuses on responding to allegations, the conclusions can also apply to adverse incidents. What are the wider implications of an incident and what steps can be taken to mitigate the effects?

The inquiry trail
When an incident occurs, most RSLs call the emergency services and take action to protect the health and safety of staff and residents. But that alone is not enough.

It's also important to consider the legal requirements for reporting the incident.

Reportable events include any that adversely affect the wellbeing or safety of service users. The 1995 Reporting of Injuries, Diseases Regulations require accidents and ill health at work to be reported to enable the HSE to identify where and how risks have arisen and to investigate serious incidents.

If the service is a registered care home, it must also report to the National Care Standards Commission.

One incident can trigger a range of inquiries, all of which can affect the organisation and the individuals involved

One incident can trigger a range of inquiries, all of which can affect the organisation and the individuals involved. HSE and NCSC investigations may trigger regulatory proceedings that may lead to the cancellation of a landlord's registration, an enforcement notice or a criminal prosecution. Disciplinary proceedings may also be required in relation to staff.

If there has been a violent or unnatural death, or a sudden death of which the cause is unknown, the coroner must convene an inquest to establish the identity of the deceased and how, when and where the death occurred. The facts from an inquest are likely to be used in proceedings such as civil action to gain compensation for damage, personal injury or death.

Basic ground rules
It's impossible to reverse an incident but much can be done to mitigate the consequences. Each incident is unique, but there are common strands.

All incidents demand an investigation into the relevant evidence, primarily by interviewing witnesses. Staff and service users may be asked to give statements – but remember that early statements given by staff still in shock after an incident may lead to inappropriate judgements or inconsistency.

All the investigations will review the organisation's compliance with internal policies and procedures, which will involve the scrutiny of records and documents. Health and safety policies and care plans are particularly important – an early internal review of compliance will often provide a useful prediction of outcome.

If averse publicity arises, speculative comment from staff is rarely helpful, so press statements should be coordinated centrally.

Managing the process
Investigative authorities have substantial powers to gain access to witnesses and most documentary evidence. Those involved can easily feel controlled by the process but measures may be taken to alleviate this:

• offer a clear and accessible policy, giving staff guidance on the management structure and how to respond when an incident occurs
  
• centralise the management of an incident by appointing a project manager
  
• conduct an early and thorough internal inquiry – consider appointing an external investigator if the incident is serious
  
• offer support for staff, particularly if their conduct has been called into account.