S.I. No. 237/2018 - Civil Liability (Open Disclosure) (Prescribed Statements) Regulations 2018

1. [Name of health services provider] was unable to establish contact with-

(a) the patient*

(b) the relevant person*

(c) the patient and relevant person*

for the purpose of arranging the open disclosure meeting on the basis of the contact information provided to it.

2. The following steps were taken by [name of health services provider] to establish contact with

(a) the patient*

(b) relevant person*

(c) the patient and relevant person*

for that purpose:[insert information on steps taken].

Signed on dd/mm/year by

Signed: ______________

Print name in Block Capitals: ______________

Principal health practitioner* on behalf of [name of health services provider].

Health practitioner referred to in section 13(1) of the

Civil Liability (Amendment) Act 2017

* on behalf of [name of health services provider].

* Delete as appropriate

GIVEN under my Official Seal,

4 July 2018.

SIMON HARRIS,

Minister for Health.

EXPLANATORY NOTE

(This note is not part of the Instrument and does not purport to be a legal interpretation)

The Civil Liability (Open disclosure) (Prescribed statements) Regulations 2018 prescribe the statements referred to in sections 16(5), 17(3), 17(5), 18(6), 19(2)(

e

)(i), 19(5) and 20(4) and the note referred to in section 17(6)(i) of Part 4 of the

Civil Liability (Amendment) Act 2017

to come into operation on 23rd day of September 2018.

3. The clarification requested was provided on: dd/mm/year.

Designated person: ______________

Print name in Block Capitals ______________

Part 2

Civil Liability (Amendment) Act 2017

Clarification of information

Statement for purposes of section 19(5) of Civil Liability (Amendment) Act 2017

Health services provider

Name: ______________

Address: ______________

Contact information: ______________

Patient*

Relevant person*

Name

______________

Name

______________

Medical Record Number

______________

Address

______________

Address

______________

______________

______________

Date of Birth

dd/mm/year

Telephone number

______________

Telephone number

______________

email address

______________

email address

______________

4. Person* (persons*) to whom the additional information was provided

(a) patient*

(b) relevant person*

(c) patient and relevant person*.

5. Where the additional information was provided to a relevant person (whether separately or with the patient)*

Name of relevant person

______________

Address of relevant person

______________

Contact information of relevant person

Telephone number: ______________

email address: ______________

6. The following additional information was provided to-

the patient*

the relevant person*

the patient and the relevant person*

at the additional information meeting.

Part 3

Additional information relating to Patient Safety Incident

7. The following additional information was provided at the additional information meeting to the person* or persons* referred to in paragraph 6

(a) description of the patient safety incident: [insert description]*;

(b) date of occurrence of patient safety incident (if known):[dd/mm/year]* [unknown]*;

(c) date on which patient safety incident came to the notice of the health services provider: dd/mm/year;

(d) description of manner in which the patient safety incident came to the notice of the health services provider:[insert description]*.

Part 4

Additional information in respect of physical or psychological consequences of the patient safety incident

8. The following additional information was provided at the additional information meeting to the person* or persons* referred to in paragraph 6 in respect of any physical or psychological consequences arising from the patient safety incident

(a) additional information provided at the meeting in respect of the matters set out in Parts 3 and 4 of the statement provided in respect of the open disclosure meeting and information given, if any, in relation to Part 5 of that statement [insert information provided];

(b) additional information on the physical or psychological consequences of the patient safety incident which, in the opinion of the health services provider, are present or have developed at the time of the additional information meeting—

(i) none of these consequences are present or developed at that time*;

(ii) description of those consequences*: [insert description];

(c) additional information on further physical or psychological consequences of the patient safety incident, which the health services provider has reasonable grounds for believing, are likely to present or develop after the date of the additional information meeting-

(i) information on those consequences which the health services provider reasonably believes are likely to present or develop after the date of the additional information meeting [insert information, if any, provided];

(ii) information on those consequences which have not presented or developed and which the health services provider reasonably believes are less likely or unlikely to present or develop after the additional information meeting [insert information, if any, provided].

(d) where the patient is under the clinical care of the health services provider which provided the additional information at the additional information meeting and any of those consequences have presented or developed at the time of the meeting and the health services provider proposes to make changes to the treatment, and relevant clinical care to address those consequences—

(i) the following information was provided: [insert information]*

(ii) the health services provider does not propose to change the treatment and clinical care*.

Part 5*

Additional information in respect of actions taken or proposed to be taken to address the patient safety incident

9. The following additional information was provided at the additional information meeting to the person* or persons* referred to in paragraph 6 in relation to the actions the health services provider has taken, or proposes to take to address the knowledge obtained from the patient safety incident including the procedures and processes to be implemented: [information, if any, provided].

[Part 6 is not to be included in statement if apology not given at additional information meeting]

Part 6*

Apology

10. An apology was made at the additional information meeting to the person* or persons* referred to in paragraph 6 [Insert statement of apology].

Part 7

Signing of statement

Signing of statement

Signed: ______________

Print name in Block Capitals: ______________

Principal health practitioner* on behalf of [name of health services provider].

Health practitioner referred to in section 18(1)(ii)* or 18(1)(iii)* of the

Civil Liability (Amendment) Act 2017

* on behalf of [name of health services provider].

*delete as appropriate

Schedule 4

Regulation 6

Part 1

Civil Liability (Amendment) Act 2017

Request for clarification of information

Statement for purposes of section 19(2)(

e

)(i) of Civil Liability (Amendment) Act 2017

Health services provider

Name: ______________

Address: ______________

Contact information: ______________

Patient*

Relevant person*

Name

______________

Name

[Full name of relevant person]

Medical Record Number

______________

Address

______________

Address

______________

______________

______________

Date of Birth

dd/mm/year

Telephone number

______________

Telephone number

______________

email address

______________

email address

______________

Notice of the making of this Statutory Instrument was published in

“Iris Oifigiúil” of

10

th July

, 2018.

I, SIMON HARRIS, Minister for Health, in exercise of the powers conferred on me by

section 22

of the

Civil Liability (Amendment) Act 2017

(No. 30 of 2017), hereby make the following regulations