What does a good quality investigation look like and how can it be achieved?

When a serious incident occurs, it is vital that the investigation process is thorough and can stand scrutiny. Getting to the heart of what went wrong and putting solutions in place to reduce the chances of a repeat incident requires an acute focus on the whole investigation process.

Investigation request

The first issue is being clear who commissioned the investigation. This is important because the investigation team need to know who they are accountable to and who to turn to for any help or support.

The investigation team adds value to an investigation when they can understand human factor theory and the principles of systems theory, which will allow them to drill down to the underlying issues surrounding the incident rather than just focusing on the person who made the mistake. The investigation team must have the right skill set to carry out the investigation and each team member needs to be clear about their individual role. The team may include staff from different disciplines or clinical backgrounds depending on the nature of the incident and should include a professional with strong investigation skills. There must also be a team leader to ensure compliance with the schedule and agreed processes of the investigation.

Terms of reference

Next, come the terms of reference. These must be clear and fit for purpose. Those affected by the incident must also be provided a copy and encouraged to read the document carefully and to allow themselves the time and space to contribute. It is fundamental that they understand the remit of the investigation and that any questions or changes are ultimately addressed in the final terms of reference. The terms of reference should describe the scope and the breadth of the investigation, clearly establishing a timeline for the investigation.

Evidence gathering

Obtaining all the evidence early in the investigation will put the investigation team onto a good footing. Your team must sure all necessary documentary evidence is received and secured and that interviews are carried out in a timely manner.

It is also crucial that you obtain benchmarks of good practice — for example, clinical guidelines, policies and procedures. These ensure you have explicit and objective criteria against which you can make solid judgements.

Interviews should be carried out sensitively in order to ensure that cognitive interviewing methodology is adhered to. This approach will encourage the interviewee to remember all the events that transpired. An enduring record of the interview should be obtained, and a copy of the transcript should be sent to the interviewee so they can sign it and send it back to the investigation team.


Once all the evidence is received it is important to develop a comprehensive chronology of events leading up to the incident.

The next step is to triangulate all evidence, if possible, to ensure its credibility. Using a tool such as a contributory factors classification system might help the investigation team to drill down to any underlying contributory or causation factors. These should be clearly linked to the evidence you have gathered.


Recommendations can be made to reduce the chances of a repeat incident once the team understands all the underlying factors.

Time is a key variable in investigations. Teams need to contemplate the implications of the investigation to determine what solutions could effectively reduce the chances of a repeat incident. Human factors are crucial to developing a recommendation. Your team members may ask themselves:

  • Is a new policy, procedure or training process really necessary, or does part of the workplace need to be redesigned and organized to minimize the likelihood of future errors occurring?

You may also consider whether a task or process needs redesigning or whether equipment needs standardising. Other things to consider might be to introduce and ensure safe staffing or the development of leadership within existing teams.

Recommendations should also be based on sustainability (how can you keep the new recommendation in place over time) and scope (which services need to change). Recommendations should be clear and measurable; in other words, based on the underlying/contributory/causal factors. You should ensure that a lead person then takes these forward, and that there is a realistic timeframe for proper implementation.

In essence: Ensure that your recommendations are specific, measurable, achievable, realistic and results orientated.

Final report

The report is often the only way that those affected by an incident can really understand what happened, why it happened and how it happened. It is therefore important that the final report is clear and concise. In this sense, accuracy and the explanation of any jargon are paramount. The report should be shared with those affected by the incident in a way and form that is appropriate.

If a member of staff has been criticised it is necessary to send the section of the report to that individual, so they can see what has been written about them, comment and send more evidence (if they chose to) before the report is finalised.

Once the investigation team are happy with the report, it should be sent to the commissioner for quality assurance.

There should be a clear quality assurance process in place so that if anyone questions any changes made, the rationale for making the change is transparent.


Gotten this far? Ensuring a high basic standard for an investigation like the one explained here should ensure that you have carried out a quality investigation that stands up to scrutiny.

For more information on the Eva serious incident investigation application then get in touch at [email protected] or call 020 7494 5676

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