Customer Incident Report
Incident Report #
Incident Definition; Acts, omissions, events or circumstances that occur in connection with providing
supports or services to or by a person with disability; and that have, or could have, caused harm to a
person with disability.
Instructions: Reporter to complete sections 1, 2 & 3 prior to the end of your shift and email to:
incidentreporting@abilitywa.com.au (cc in your line manager).
Coordinator/Team Leader to compete sections 4 & 5 and email to: incidentreporting@abilitywa.com.au (cc in
your line manager) Manager to complete section 6 and email to: incidentreporting@abilitywa.com.au
1. Reporter details
Staff Karma Contact 0433838788 Position SW
Name: details: title:
Division: ✘ Community Services Therapy Enterprise Services
Business Unit: ✘ Supported Independent Living (SIL) Opportunities Short Term Accommodation
Therapy Goodwill Engineering Employment Services CDS
Sub Division: SIL South SIL Central ✘ SIL North SIL Coolbinia SIL ILO STA CP Tech
Opportunities Opportunities External Therapy North Therapy South Therapy Central
2. Incident category / Subcategory (reporter to complete)
Incidents in red text require an NDIS reportable incident (Manager to complete)
Restrictive Practice Unauthorised restrictive practice use
Customer Harm to Self Harm to Others Physical aggression
Behaviour of Verbal aggression Property damage Threat
concern Sexually inappropriate Mental health concern Unexplained absence
Medication error Wrong person Missed Unsigned
Wrong dose Customer declined Other:
Wrong time Pharmacy related error
Fall From height From sitting While assisted
From standing Not witnessed
Equipment (i.e. PEG Hoist Wheelchair
error) Catheter related Other (detail):
Substandard Care Manual handling error ☐ Other (detail):
Care plan not followed (detail plan type):
Other injury or Unplanned hospitalisation Bowel care unknown cause
illness (illness) Seizure Skin
Unplanned hospitalisation Death Integrity/pressure
(injury) sores
Other (detail):Thelma refused for shower and cloths change
Near Miss Near Miss
Safeguarding Safeguarding concern
Concern
Staff Error Staff error
Abuse & Neglect Physical Neglect Sexual Financial Verbal (allegations included)
(of customer)
3. Customer & Incident details (reporter to complete)
Date of Report: 12/11/2023
Date of Incident:
12/11/2023 Time of Report: 1200
Time of incident:
1200
Customer Name: Thelma Welsh Customer DOB: 09/11/1961
SIL house name: 9 blackbutt court, Morley Coordinator Name:Loise Wagari
Staff: Witness Name & Contact details:
Others involved
Customer/s:
Did the incident cause Harm to the customer? Yes ✘ No
Location of incident: ✘ Home School In the community
Vehicle Workplace Other (please detail):
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Customer Incident Report
Incident Report #
What was happening before the incident?
She was relaxing in her when chair in the sitting room.
What happened? Please provide summary of incident - include impact on/harm caused to the person
Thelma refused for shower and cloths change
What happened after? How did you respond/What did you do to help make the person safe?
Explained her the importance of hygiene and importance of cleanliness.
What actions have been taken in response to the incident: for example, to support customer involved
Informed her on health issues and importance of staying heathy.
Who was contacted:
Nurse/Health Lead notified Coordinator / Team Leader
Ambulance called Manager contacted
Report to police Parent/Guardian notified
Report to CPFS/Child Protection Other (please detail):
✘ On call Manager contacted
Could this incident have been prevented? (please provide details)
If she could be reminded time and again the importance of hygiene and cloths change.
Reporter – end of customer / incident details. Please keep this report in Word format, do not PDF.
Please email incidentreporting@abilitywa.com.au & your Coordinator/Team Leader - prior to the end of
the shift or within 24 hours. Please include documents of relevance that may help to provide additional
information i.e. photos, health support form, medication signing sheet, communication diary notes etc.
4. Incident Review Process (Coordinator/Team Leader to complete Sections 4 & 5)
Actions taken to manage risk / prevent further similar actions occurring? (consider preventative
& corrective measures for both customer & staff)
Changes to service as a result of the incident?
How well was the incident managed/resolved? ✘ poor average good
Provide an objective response on how the entire incident was managed.
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Customer Incident Report
Incident Report #
Consultations undertaken with the customers affected by the incident
Who made contact/when? Advocacy referral? Include details of consultation/outcome.
Has the customer been provided with findings related to the incident/how it was managed?
Have staff been provided with feedback and/or outcomes relating to the incident?
5. Post incident activity (Coordinator/Team Leader to complete Sections 4 & 5)
Investigation required - Operational People & Culture Quality Governance
Performance issue escalated to People & Culture – Date:
Referral to PBS Practitioner – Date:
Risk assessment undertaken - Date:
Debrief (submit debrief form with report) - Date:
Reportable Incident form / Serious Incident Form required (Manager required to complete)
If Abuse/neglect – have advocacy materials been provided Yes No Date:
Has Parent/Guardian been contacted? Yes No Manager advised? Yes No
Other External Advocate Legal Representative Mental Health Service
reporting completed: Agency Child Protection & Family Support Dept of Justice
Coroner Office of Public Advocate/Guardian Police
Alert/Risk Profile to be completed if applicable Yes Not applicable
Coordinator/Team Date completed
Leader Name or sign: & sent to Manager:
Coordinator/Team Leader to email incidentreporting@abilitywa.com.au and Manager
6. Manager closure (Manager to complete)
Has a Reportable Incident/ SIR been submitted No Not required Yes Date submitted:
Are you satisfied with the actions taken in response to the incident? Yes No (complete below)
Any further actions required?
Any incident review/investigation findings or outcomes?
Manager name or sign: Incident Closure Date:
Manager to email incidentreporting@abilitywa.com.au to close the incident
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