Sample policy · Reg 12

Medical Emergencies and Deteriorating Patient Policy

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 18 (staffing), Regulation 15 (premises and equipment) and Regulation 17 (good governance). · primary source

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Verivius pack version v1.1, 2026-07-19

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

where equipment or medicines are supplied by the service provider, ensuring that there are sufficient quantities of these to ensure the safety of service users and to meet their needs, (Reg 12(2)(f) (sufficient equipment + medicines supply))

the proper and safe management of medicines, (Reg 12(2)(g) (medicines management))

Regulation 18 adds the staffing and competence duties that this policy relies on:

Sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed in order to meet the requirements of this Part. (Reg 18(1): the headline duty)

receive such appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. (Reg 18(2)(a): support, training, supervision and appraisal)

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/18. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Alongside this, Regulation 18 requires you to deploy enough suitably qualified, competent, skilled and experienced staff, and to give them appropriate support, training, professional development, supervision and appraisal. For medical emergencies and deterioration, this means trained staff, available and checked equipment and emergency medicines where required, and a reliable escalation route.

3. Purpose

The purpose of this policy is to make sure that [Service Name] can recognise, respond to and escalate medical emergencies and deterioration promptly and safely.

Medical emergencies may happen in any regulated service, including clinics, treatment rooms, diagnostic services, dental services, patient transport, care homes, domiciliary care and specialist services. The service must have clear arrangements, trained staff, available equipment, emergency medicines where required, and a reliable escalation route.

This policy supports Regulation 12 safe care and treatment, Regulation 17 good governance, Regulation 18 staffing, Regulation 15 premises and equipment, and the provider's duty to protect people from avoidable harm.

4. Policy warning

A medical emergency must never be treated as an ordinary appointment, visit, transport problem or administrative event.

Where a person is acutely unwell, deteriorating, collapsed, experiencing serious symptoms, or appears to need urgent assessment, staff must act immediately, call emergency services where required, and escalate to the senior person on duty.

Delay in recognising or escalating deterioration can cause serious harm and may require incident reporting, safeguarding review, duty of candour, CQC notification or professional-regulatory referral.

5. Scope

This policy applies to emergencies and deterioration involving:

It includes:

5.1 Local decisions before adoption

Before adoption, the service records:

Staff must be able to find these local arrangements during an emergency without searching through this full policy.

6. Principles

The service will make sure that:

The service will not ask staff to manage an emergency beyond their training, competence or role.

7. Responsibilities

The Registered Manager is responsible for ensuring that emergency arrangements are in place, staff are trained, equipment and medicines are checked, and incidents are reviewed.

Clinical leads or competent senior staff are responsible for advising on service-specific emergency risks, emergency medicines, equipment, training and escalation routes.

All staff are responsible for recognising concerns, calling for help, following local procedures and recording what happened.

The provider or Nominated Individual is responsible for ensuring that the service has the resources needed for safe emergency preparedness.

8. Emergency risk assessment

The service must assess the likely emergency risks linked to its regulated activities.

The assessment must consider:

The emergency risk assessment must be reviewed annually and whenever the service model changes.

9. Recognising deterioration

Staff must be alert to signs of deterioration, including:

Where staff are worried, they must escalate. Staff must not wait for a complete set of observations before calling for help if the person appears seriously unwell.

10. Immediate response workflow

In a medical emergency, staff must:

Staff must not leave the person alone unless this is necessary to get urgent help and there is no safer alternative.

11. Calling emergency services

Staff must call 999 immediately where there is:

Where staff are unsure, they must err on the side of safety and seek urgent advice.

12. Basic life support

Staff whose role requires basic life support must receive training at a level appropriate to their role and service type.

The service must identify:

Training must be recorded on the training matrix.

13. Emergency medicines

Where emergency medicines are required by the service type, procedure or risk assessment, the service must ensure that they are:

The service must have a separate Emergency Medicines and Equipment Checking Policy or procedure.

14. Emergency equipment

Emergency equipment must be available where required by the service type and risk assessment.

This may include:

Equipment must be checked, maintained and replaced in line with the service's checking procedure.

15. Handover to emergency services

When emergency services arrive, staff must provide a clear handover including:

The handover must be documented.

16. Communication with family or representatives

The Registered Manager or senior person must decide who should be informed and when.

Where appropriate and lawful, the service must inform:

The record must show who was informed, when, by whom and what information was shared.

17. Recording

After a medical emergency, the service must record:

Records must be factual, timely and complete.

18. Incident review and learning

Every medical emergency must be reviewed as an incident.

The review must consider:

Findings must be added to the action plan or risk register where appropriate.

19. Staff support

Staff involved in a medical emergency must be offered support and debriefing.

The debrief must consider:

Support does not replace investigation where there are concerns about practice.

20. Testing and drills

The service must test emergency arrangements at least annually, or more often where risk requires.

Testing may include:

Tests must be recorded and actions tracked.

20.1 Audit and monitoring cadence

21. Related policies

This policy should be read with:

22. Review

This policy will be reviewed annually, or sooner following a medical emergency, serious incident, CQC finding, equipment failure, medicines incident, change in service type, change in national guidance or emergency drill finding.

23. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

24. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

25. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Added local emergency decisions, an explicit response workflow and measurable assurance cadence.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Most independent services will go years without a cardiac arrest, and that is exactly the risk: the failure is rarely a lack of skill, it is the hesitation of a team that has never done this together. The events that catch these services arrive minutes after something routine, anaphylaxis after a local anaesthetic, an injection or a vaccine, a faint that turns out to be a cardiac event, a diabetic collapse in the waiting room, deterioration after a procedure, or somebody found unwell in a transport vehicle or their own front room where there is no crash team and no second clinician. It gets missed because the appointment was booked as routine and everyone present, including the person and their family, is still reading it that way. What decides the outcome is the gap between the moment somebody first thought this person looks unwell and the moment help was called, and that gap only exists in the record if the times were written down while it was happening. Getting this right is what turns a frightening few minutes into care the person and their family can still trust afterwards: somebody stayed with them, the ambulance crew were told the allergies and the medicines, and the family were told what happened and by whom. Inspection reads the same trail, but the plainer reason to keep it is that it is the only honest way to find out whether your own team would freeze.

  1. The emergency kit is genuinely checked and ready, not just present on site: the daily or per-session check has actually been done and items are in date and accessible, so the kit works when someone collapses, rather than a trolley that has sat unchecked.

    Strong evidence: The locally-approved emergency-medicines and equipment check completed each opening day or clinical session, and the monthly review of missed checks, expired or replaced items and overdue actions (section 20.1).

    Weak evidence: A check sheet carrying a month of identical ticks in the same pen, including ticks on days the service was closed, with no column for what was actually found: no expiry dates written down, no note of the adrenaline that was swapped, nothing on defibrillator pad or battery expiry. Weakest of all is a sealed, complete trolley on the day of the visit that nobody can say who last opened, or when. The daily or per-session rhythm and the monthly review are the cadence we recommend; what is not optional is that the kit is genuinely in date, sufficient and reachable.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  2. Deterioration is escalated promptly, not held back until a full set of observations has been gathered: the real-world failure is staff finishing the observation chart before calling for help when the person is already seriously unwell.

    Strong evidence: The post-emergency record showing the time symptoms or the incident started against the time 999 was called and the senior lead informed (section 17), read against the rule that staff must not wait for a complete set of observations before calling for help if the person appears seriously unwell (section 9).

    Weak evidence: A record that begins at the point 999 was called, with nothing showing when the person was first noticed to be unwell or who raised the concern. The other tell is a neat, complete set of observations timed in the minutes between the first sign of collapse and the emergency call, which shows the team finished the chart before they got help. Family or staff saying something is seriously wrong, and that concern going nowhere, rarely appears in the record at all, even though the policy treats it as a trigger to escalate in its own right.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  3. The staff on duty are trained to the level their role actually requires, not just trained in general: basic life support is at the right level (adult, child or infant), refreshers are current, and it is clear who may use the defibrillator.

    Strong evidence: The training matrix recording basic life support level, refresher frequency, defibrillator authorisation and how competence was recorded (section 12).

    Weak evidence: A training matrix with one column headed basic life support and a date beside each name, no level recorded, so nobody can tell whether the staff who see children have ever practised on a child or an infant manikin. Refreshers quietly out of date for the people most often on duty alone, or agency and bank staff who appear on no matrix at all. On the defibrillator, the thin version is everyone counted as covered because the device talks you through it, with no record of who was actually shown it, when, or what the limits of their role are. The duty to deploy staff with the competence and training their role requires is statutory; the adult, child and infant levels and the refresher intervals come from Resuscitation Council UK guidance rather than from the regulation.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  4. Each emergency is reviewed and the learning closed, not just recorded: the review actually asks whether recognition and escalation were timely, whether equipment and competence were there, and whether the resulting action was checked to have worked.

    Strong evidence: The incident review covering prompt recognition, timely escalation, equipment availability and staff competence (section 18), and the section 20.1 requirement that after every emergency or failed drill the owner records learning, assigns actions and checks the change worked before closure, with findings added to the action plan or risk register.

    Weak evidence: A review form filled in the same afternoon reading 'staff followed procedure, no further action', with nothing on timing and no answer to whether the kit and the competence were actually there. More common is a live-looking action, 'remind staff at team meeting', assigned, marked complete once the meeting happened, and never tested against a later emergency or drill to see whether recognition and escalation improved. If nothing from an emergency ever reached the action plan or risk register, the reviews are recording events rather than changing anything. Checking that the change worked before the action is closed is the mechanic we recommend; running a system that assesses, monitors and improves the safety of care is the statutory part.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

  5. Any duty-of-candour decision is made against the defined Regulation 20 threshold for a notifiable safety incident, which is a high bar (death, severe harm, or prolonged pain or prolonged psychological harm lasting at least 28 days, with moderate harm additionally in scope only for NHS-body providers). The duty of candour is owed to the person and is not a notification. A CQC notification is a separate duty under the registration regulations, weighed in its own right, so neither is assumed to trigger, or not trigger, simply because an emergency happened.

    Strong evidence: The post-emergency record showing whether safeguarding, duty of candour, CQC notification and the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) were each considered (section 17), and the review's finding on whether duty of candour applied and whether external notification was required (section 18).

    Weak evidence: A box ticked 'duty of candour: not applicable' with no reasoning recorded, so there is no way to see the threshold was ever applied. The mirror image is just as weak: an apology letter for every ambulance call, which buries the genuinely notifiable safety incidents. The clearest sign the two duties were never weighed separately is a single tick covering duty of candour and CQC notification together, or a record where safeguarding, a professional-regulator referral and a notification have been treated as one decision rather than three. Providers who are not health service bodies also tend to apply the wider NHS threshold by habit, which is a different test.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 20(2)-(3) with the notifiable safety incident thresholds at reg 20(8) (health service bodies, moderate harm in scope) and reg 20(9) read with the reg 20(7) definitions of prolonged pain and prolonged psychological harm (28 days); CQC (Registration) Regulations 2009, regs 16 and 18

  6. Emergency arrangements are rehearsed for real, not just logged on paper: a scenario drill actually runs at every material location and tests the response expected of both clinical and non-clinical staff.

    Strong evidence: The at-least-annual scenario drill records at every material location (section 20.1) and the recorded tests and tracked actions under section 20.

    Weak evidence: A drill log with one entry a year for the main site and nothing for the branch clinic, the treatment room, the transport fleet or the domiciliary team, so the places with the thinnest cover are the places never tested. Thin drills read as a room of clinical staff talking a collapse through: no reception, housekeeping or driving staff involved, no times recorded, and no note of what went wrong, which is the only part worth keeping. At least annually at every material location is the cadence we recommend, and a drill that produced no actions usually means nobody was allowed to fail it.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 20 July 2026

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Last reviewed 19 July 2026