Lessons learned diagnostic assessment of an NHS trust and its processes

Lessons learned diagnostic assessment of an NHS trust and its processes

The client

Mental health foundation trust – Healthcare


Serious Incidents.
Our challenge was to review whether sustainable solutions had been put in place at the trust, following a series of serious incidents.


The associate director of quality governance and performance commissioned us to carry out a lessons learned diagnostic assessment of the entire trust and its processes.


Our team, Verita director Chris Brougham and Verita senior consultant Gemma Caprio, examined systems and processes and interviewed staff to find out what aspects are going well and whether there is a need for any improvements.
We used the Verita diagnostic toolkit to investigate five components that underpin performance. Our diagnostic tool is based on national best practice in the management of learning lessons. This report highlights the main findings of the assessment in the five areas.

  1. Board recognition – How much attention is paid by the board to serious incidents? Which reports and action plans do executives see? How do executives interact with the governance team?
  2. Resources and infrastructure – Is the trust adequately resourced to put new improvements in place? How much engagement is there with clinical divisions? Is interaction with clinicians effective?
  3. System efficiency and quality -How are serious incidents triaged/allocated? What deadlines are set? Are deadlines met? What is the quality of the investigation reports and action plans?
  4. The investigation – Are there clear terms of reference for the investigation? Does the report contain a clear chronology? Is evidence benchmarked and are recommendations Specific, Measurable, Achievable, Realistic and results orientated and do they have a Timescale (SMART)? Does the report identify the issues that caused or contributed to the incident? Are patients informed when they have been harmed? Are patients/families supported throughout the process? Are the findings of SI investigations shared with the patient/family in a timely way?
  5. The action plan – Are recommendations SMART and does the action plan address all the points? Does the current system encourage systematic learning from serious incidents? Are trends analysed and translated into changes in practice?

Each question is based on best practice and the trust’s performance is scored (maximum score 100 per cent) against it.

In order to gain insight on each of the areas of investigation we used a combination of testimonial and documentary evidence.

Our interviewees included NEDs, the director of finance, the director of nursing, the medical director, risk managers, heads of governance, clinicians and service managers.

We reviewed trust policies and procedures and other relevant documentation. These included:

  • board performance reports and board minutes;
  • quality and risk minutes and papers;
  • serious incident policy, serious incident investigation template, sample terms of reference;
  • a selection of recently completed serious incident investigation reports, action plans and audits;
  • a selection of recently completed quality improvement audits; and
  • clinical incident review minutes and reports.


We found elements of good practice though some areas require further development.
The particular areas which require further strengthening are in relation to board recognition, and action planning following a serious incident.

We heard from trust board members that the trust board had two executive directors who lead the governance agenda. Staff that we interviewed who were not on the trust board were unsure of the exact roles and responsibilities of each director. Staff told us that they were unsure if the trust board received details of the progress and completion of action plans relating to serious incidents.

Some staff highlighted they encounter difficulties completing investigations and proposing recommendations within the required timescale. Investigations are viewed as an addition to an already heavy workload. Investigation deadlines are rarely missed but staff felt under resourced. Some staff told us there is limited opportunity for joint working between incident investigations and the complaints team in the division.

We heard from staff at all levels that there are sometimes problems in ensuring recommendations are SMART. We were also told recommendations were not always easy to implement and the same recommendations were made in different investigation reports. The investigation reports we reviewed detailed the version number on the front page. This could prove confusing for families.

Recommendations & Outcomes

Our recommendations covered communicating roles and responsibilities better, reviewing the financial and organisational impact of serious incidents, improvements in training and benchmarking the quality of investigations.