Conducting an investigation: essential steps
Be clear about what you are doing
Think about why you need an investigation and what you want it to achieve.
Write the terms of reference
Having established a clear purpose, write it down and clear it with your lawyers. Do not automatically commit the organisation to full and open publication of the final report, because there may be reasons that are not immediately apparent why you should not.
Retrieve and safeguard the evidence
Recover and keep safe all relevant documents and records as soon as possible. This minimises loss or changes after the event. Keep a log of what you recover. If a crime may have been committed, cordon off the area before the police arrive.
Make immediate improvements
If you know what went wrong take immediate action to put it right; do not wait for the investigation report. Otherwise you risk the problem recurring and being criticised for being slow to respond, or worse.
Support staff and victims
An adverse incident can affect everyone involved. Make sure you support everyone, not just the obvious victims. Bring in specialists if necessary.
Appoint the investigators
Select the investigators carefully, with an eye to the skills and expertise needed to carry out the investigation effectively - and to the level of independence and authority required. The credibility of the investigation will depend on these people.
Manage the investigative process
Consider providing administrative support to keep the investigation on track. Independent investigators will automatically provide this service themselves. But if you choose to appoint an investigative panel and chair (typically a barrister), responsibility for managing the process rests with the commissioning organisation.
Implement the recommendations
Act on the recommendations. If there are recommendations that you are not prepared to implement, explain why.
Whether or not the investigation report is published, you will need to communicate what went wrong, the lessons learned and the actions taken. Decide who you need to tell, what you need to say, how you are going to say it, and when.