Serious Incident Investigation

Verita are leading UK independent consultants who believe in improvement through objective investigation.

Serious incidents requiring investigation

At verita, our experience as a serious incident investigator, provides us with an understanding that weaknesses in serious incident investigations can lead to reputational damage and costly legal claims, as well as missed opportunities to make services safer.

Our serious incident management service ranges from conducting individual investigations and thematic reviews, to consultancy, training and diagnostics.

We have drawn on our experiences with health organisations investigating over 200 serious incidents to develop solutions that give the information needed to target problem areas, quality assure investigations and investigative processes, prevent serious incident backlogs and increase organisation-wide learning.

Verita have helped health providers improve such that the regulator has lifted warning notices about their serious incident processes. NHS trusts come to Verita to assure themselves and the regulator that they have robust policies and systems in place to investigate serious and critical incidents to generate reports where themes are identified and lessons learned.

We assess individual serious incident reports and conduct thematic reviews of multiple reports to flag areas of weakness and offer evidence-based recommendations on how to improve.

We also help your teams with the implementation of PSIRF (Patient Safety Incident Reporting Framework) during the transition from the Serious Incident Framework.

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Serious incident investigator services

We are a specialist incident investigator able to write adverse incident handbooks and deliver systematic incident investigation training for organisations to help them embed and maintain robust systems for managing serious incidents. Our CPD accredited training covers each step of the systematic investigative process including root cause analysis.

Our courses teach techniques on applying human error theory, securing and collating evidence, using investigative tools, developing chronologies, analysing evidence, writing reports and developing SMART recommendations.

We also test the strength of newly introduced serious incident policies by benchmarking against national standards and meeting with senior staff across clinical directorates to assess their understanding and emphasise the importance of conducting and learning from investigations.

We identify ways in which such policies and their implementation can be improved and put forward practical recommendations on how organisations can embed learning from a serious incident investigation.

Serious incident investigator tools

In order to better achieve this, we employ the use of our ‘serious incident diagnostic tool’ to help trusts pinpoint weaknesses in their serious incident management processes, often in trusts with a backlog of cases pending investigation. Using our tool we test compliance against seven best-practice standards drawn from national guidance: board recognition, system efficiency and quality, staff engagement, resources and infrastructure, the investigation, learning from serious incidents and involving third parties.

Our diagnostic identifies whether boards are committed to investigating serious incidents, whether teams are adequately resourced, whether authors are sufficiently challenged and whether action plans are SMART. We also assess whether third parties are involved in investigations in accordance with local and national guidelines.

We offer practical advice on effectively managing serious incidents the first time. This advice is grounded in our experience, national guidance and the use of interview testimony and documentary review. The result is a reliable and cost-effective service that promotes learning and helps to reduce the need for later expensive action.

To find out more about how our serious incident investigator services can benefit your organisation, please contact Verita founder Ed Marsden on 020 7494 5670 or via email at [email protected].

Key Team Members

Ed Marsden
Ed Marsden has a clinical background in general and psychiatric nursing and NHS management, and has worked for the Department of Health and the West Kent Health Authority as director of performance management.

He combines his responsibilities as Verita’s founder with an active role in leading complex consultancy and investigations. He worked with Kate Lampard to provide independent oversight of the 40 or so investigations carried out by the NHS into allegations about Jimmy Savile. Recent work includes leading a review of patient safety at Great Ormond Street Hospital for Children, and investigating the work-related death of an NHS manager.

Peter Killwick
Peter has 25 years of consulting experience covering a variety of strategic and operational issues in a wide range of sectors including healthcare.

He has extensive experience of conducting complex investigations within the NHS, both at operational and commissioner level, including several cases involving allegations raised by whistle-blowers.

Nicola Salmon
Senior consultant Nicola Salmon has conducted patient care reviews for acute and mental health NHS trusts and investigated human resources and governance issues for clients such as Public Health England and NHS England.

Nicola has also been part of investigation teams reviewing governance concerns including conflicts of interest between officers and whistleblowing complaints. She is a qualified ‘Professional Safety Investigator’ having received a Level 3 award in 2022.