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Risk management

What is risk?

Risk is defined as 'exposure to chance of injury or loss' and is associated with people (ie staff, patients, and visitors), reputation, financing, buildings, the estate, equipment, consumables and processes.

Risk management

This is a process of identifying and evaluating potential and actual risks in order to eliminate or control such risks so as to protect the safety and well-being of patients, visitors, staff and the assets and reputation of the organisation.

Roles and responsibilities for risk management at Papworth Hospital

  • The chief executive has overall accountability for risk management within the Trust. All employees are individually responsible for ensuring that they perform their duties and conduct themselves in ways that minimise or eliminate risks to patients, staff, visitors and hospital property, including the reporting of potential or actual risks and adverse events.
  • The executive lead for governance and risk is the director of nursing.
  • A non-executive director chairs the Quality & Risk Committee (a committee of the Board of Directors) which meets quarterly. It is the responsibility of the Quality & Risk Committee to assure the Board of Directors that effective risk management systems and processes are in place throughout the hospital. Achievement of that goal is the responsibility of the Quality & Risk Management Group and the various committees and groups which report to it.

View the current clinical governance and risk management structure chart

  • Chief Executive: Mr Stephen Posey
  • Clinical Governance Manager: Ms Carole Buckley
  • Risk Manager: Ms Anna Pearman

The Trust has an agreed Risk Management Strategy that outlines the overall objectives of our risk management processes. If you would like a copy of this document, please email

Risk Register

The Risk Register is managed by the Risk Manager and provides a means for managers to record risks in their areas of responsibility and the actions they are taking to minimise or eliminate those risks. It is used to inform capital planning decisions and to alert the Board of Directors about significant or uncontrolled risks. The register is reviewed regularly by the Quality & Risk Management Group, which also monitors progress with actions to reduce or control risks, and significant risks are reported quarterly to the Quality & Risk Committee by the Director of nursing. Changes to risks are also reported via the Quality & Safety quarterly report.

Accident/incident reporting system
A hospital-wide electronic adverse event reporting system is in place and all reports are initially reviewed by the relevant line managers, who also determine any required corrective actions. Further investigation of adverse events and monitoring of action plans is co-ordinated by the Clinical Governance & Risk Management Team, Whenever appropriate, external agencies are notified of serious events e.g. The Health and Safety Executive, The Medicines and Healthcare Products Regulatory Agency, Clinical Commissiong Groups (CCGs)  and the Care Quality Commission. Reports of adverse events are reviewed regularly by the Quality & Risk Management Group, the Medicines Safety Group and Business Unit meetings. Anonymised reports of all patient related incidents are submitted to the National Reporting & Learning System database (NRLS).

Safety alerts
The Risk Management Team is responsible for ensuring that safety alerts received by the Trust are assessed for relevance, and where appropriate suitable action plans are developed and progressed to ensure timely compliance with the alert.


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