Improving the quality of serious incident investigations at a mental health trust

Improving the quality of serious incident investigations at a mental health trust


Verita was commissioned by a director from a mental health trust to improve the quality of serious incident investigations produced by investigators at the trust. The trust’s commissioners were unsatisfied with the standard of the trust’s investigations and refused to sign off the reports.


Verita provided external support to the trust by quality assuring a representative sample of serious incident reports, identifying areas for improvement and delivering a bespoke training course to the trust’s investigators.


Verita quality assured 35 serious incident investigations produced by the trust. Using the findings from this exercise Verita devised and delivered a one-day systematic incident investigation training programme for all staff who had the responsibility for carrying out investigations. The programme focused on aspects of poor practice the trust was demonstrating and provided practical tools and techniques for making improvements. Course participants worked in investigation teams to investigate a serious incident case study. The course covered every step of the investigation process. This included:

  • theory on why we make mistakes (human factors)
  • commissioning the investigation
  • developing the terms of reference
  • setting up the investigation team
  • gathering and securing evidence
  • investigative tools and models
  • developing a comprehensive chronology of the incident
  • determining key lines of enquiry and analysing information
  • finding the contributory factors and root causes of why something went wrong
  • tips on writing the investigation report
  • developing recommendations that are specific, measurable, achievable, relevant and time scaled (SMART).


Our quality assurance work identified that only 30 of the 35 reports reviewed contained clear terms of reference and that the quality of analysis across all 35 reports was poor. Only nine of the reports listed recommendations that were SMART.


Verita received great feedback from delegates attending the course who advised that they felt more confident in carrying out a serious incident investigation. More importantly the trust advised us that their commissioners had noted a positive difference in the quality of the trust’s investigation reports.