Serious incident diagnostic assessment of systems – acute foundation trust

Serious incident diagnostic assessment of systems – acute foundation trust

The client

An acute foundation trust – Healthcare


Serious Incident.

This trust asked Verita to carry out a serious incident diagnostic assessment to find out which aspects of the system were working well and whether there was a need for improvement.


Using a combination of testimonial and documentary evidence, Verita reviewed the policies and procedures across the trust in order to establish areas of weakness.


Verita director Chris Brougham and senior consultant Gemma Caprio used the Verita diagnostic toolkit to investigate seven components that underpin performance. Our diagnostic tool is based on national best practice in the management of serious incidents and the duty of candour. This report highlights the main findings of the assessment in seven areas.

  1. Board recognition – How much attention is paid by the board to serious incidents? Which reports do executives see? How do executives interact with the patient safety team?
  2. 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?
  3. Staff engagement – How much engagement is there with clinical divisions? Is interaction with clinicians effective?
  4. Resources and infrastructure – Are staffing levels sufficient? Is the IT infrastructure suitable? Do staff receive appropriate training? Are roles and responsibilities clearly defined?
  5. 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).
  6. Learning from serious incidents – Does the current system encourage systematic learning from serious incidents? Are trends analysed and translated into changes in practice?
  7. Duty of Candour – involving and supporting patients and their families – 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?

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 team interviewees included the chief nurse, the deputy director of performance, the trust secretary, the acting medical director, the head of nursing, a NED, ward managers, a clinical lead for quality and governance and CCG representatives.

Our team reviewed trust policies and procedures and other relevant documentation including:

  • a selection of recently completed serious incident investigation reports;
  • being open and duty of candour policy, and procedures;
  • policies and procedures for serious incident investigation;
  • minutes from the trust governance and assurance committee;
  • trust root cause analysis toolkit; and
  • serious incident report template.


We found elements of good practice though some areas require further development.
The particular areas which require further strengthening are in relation to system efficiency and quality, staff engagement and the investigation.

Some staff highlighted they encounter difficulties completing SI investigations 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 interviewed told us that there is limited joint working between PALS and the SI team to ensure any complaints or concerns are coordinated on some occasions, we heard this process was dependant on the individuals involved.

Some front line staff told us that feedback is not always received from some of the low level incidents recorded on Datix. A more structured approach to providing feedback to staff would be beneficial.

We heard that announced and unannounced walkabouts by directors are in place. These could be further improved by focusing on incidents and monitoring the outcomes.

We heard from some staff that there is sometimes confusion of the boundaries of each role in the investigation process. It is important to ensure the patients and families receive unambiguous information from each member of the clinical team and investigation team.

Recommendations and Outcomes

Our recommendations covered ensuring that investigation teams are fit for purpose, that they have a clear lead, contain the correct skill mix and that clinicians are clear about their roles. We also recommended that each serious incident report contains, amongst other features:

  • clear terms of reference;
  • clear description the incident and consequences;
  • SMART recommendations; and
  • include the details of who peer reviewed the investigation report.