Serious Incident Report Form

This report should be prepared for any incident to any client, visitor or staff member that occurs on
premises that is not minor.
An incident is not minor and requires a report if:
▪ the incident resulted in death, injury or hospitalisation
▪ there is an injury to the head or where a person loses consciousness
▪ a person sustains an injury to the eyes or where teeth are broken or dislodged
▪ a person sustains broken bones or lacerations requiring sutures
▪ it is necessary to transport an injured person to hospital
▪ medical attention is provided on site by an ambulance officer or health care professional or such
treatment is reported by the student, visitor or parent at a later date
▪ an incident occurs during the use of a school facility by a community group.

Personal Details of Client/Visitor/Staff Member

First name: Mark

Family name: Xyz

◻ Employee
◻ ✔️Client✔️
◻ Contractor/Volunteer
◻ Visitor
◻ Agency Casual

D.O.B: ___01_ / _04___ / Age:52

__1972__

Department:

Name of emergency Banksia Residential care

contact:

Address: Not given

Contact Phone Number: 0403119214

Incident Details

Date: __22__ / __08__ / Day of Week: Tuesday

__2024__

Time: _____10____ a.m. / Location: At clients home

p.m.

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Describe the incident, illness, trauma or injury sustained:

Had a fall in the bathroom while exiting sustained head injury ambulance called

State exactly what happened:

The client fell when he was exiting the shower. He slipped and hit his head on the towel hanger, and a
large wound opened up just above his eye. He was taken to hospital because of the injury and
incident. There is sizeable bold spill on the floor where the incident happened. While I was cleaning up
the blood spill I noticed that the bathroom mat is not secure and looks like it came out from under his
foot. There is also no grab bar to assist mark as he exits the shower. The towel hanger is bent and
broken mist likely because mark tried to grab it for balance because there is not grab bar. And this
could mostly likely what caused him to fall and hit his head.

Medical/treatment details:

Was first aid given by staff? ✔️Yes

◻ No

Was further medical attention ◻ Yes Ambulance called staff took care
given?
lTransferred to hospital
◻ No
If yes, on whose
authority?
◻ Doctor
◻ Nurse
◻ Counsellor
◻ Other: _____Ambulance staff____________________

Subsequent treatment (if known)

Certification

Emergency contact of affected person has been notified if practicable? ◻ Ye ◻ N

s✔️ o

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The affected person has been kept under observation for a reasonable period? ◻ ✔️ ◻ N
Ye o
s

First Aid provided? ◻ ✔️ ◻ N

Ye o
s

Medical assistance has been obtained? Ambulance called ◻ ✔️ ◻ N

Ye o
s

Name of person completing the Muhammad Ali

form:

Signature: MAli Date: __22__ / _05___ /

__2024__

Witness to Incident

Full Name: Non

Address: Post Code:

Witness Contact Number:

1. When did the incident occur?

N/A

2. Where did the incident occur?

At the bathroom of Banksia care Residential home

3. What activity was the person engaged in?

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Taking a bath

4. How did the incident occur?

Be sure to mention any article, or aspect of the environment which was involved e.g. slipped in a bathroom, fell from a bed,
etc.

Slipped in the bathroom head struck with the towel rod while exiting when noticed the bath may was
properly fixed and no support bar was present near towel rod .

5. What were the injuries/suspected injuries?

Head injury with perfused bleeding above eye ball

6. What treatment for the injury/injuries (if any) was provided at the place where the incident occurred?

Gave first aid called the ambulance

7. Who was the affected person first referred to?

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Ambulance staff

8. Who was present when the incident occurred?

9. Name of staff member(s) responsible for supervising the area at the time of the accident.

Muhammad Ali

10. If you witnessed the incident please sketch the incident scene (marking your location, the location of
the affected person, any buildings or other clients or staff present, any other landmarks) in the box
below.
Your location should be marked with an X and the location of the affected person should be marked with a Y.

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Unwitnessed as he was in the Bathroom

Signature: ____________M.Ali____________________________

Statement by injured/affected person:

My full name is: Mark

My address is: Banksia Residential home Post Code:

My D.O.B is: Xyz My age is:

I am an:
◻ Employee
◻ ✔️Client
◻ Contractor/Volunteer
◻ Visitor
◻ Agency Casual

Write in your own words what happened:

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The client fell when he was exiting the shower. He slipped and hit his head on the towel hanger, and a
large wound opened up just above his eye. He was taken to hospital because of the injury and
incident. There is sizeable bold spill on the floor where the incident happened. While I was cleaning up
the blood spill I noticed that the bathroom mat is not secure and looks like it came out from under his
foot. There is also no grab bar to assist mark as he exits the shower. The towel hanger is bent and
broken mist likely because mark tried to grab it for balance because there is not grab bar. And this
could mostly likely what caused him to fall and hit his head.

Please draw a sketch to accompany your statement (marking your location, any buildings
or other clients or staff present, any other landmarks) in the box below. Your location should be
marked with an X.

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Signature: ___________M.Ali_____________________________

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