Serious Incident 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.
To find out more about our serious incident investigator service can benefit your organisation, please book a free consultation or simply call us on 020 7494 5670 so we can discuss your needs.
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How Verita can help
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.
Common themes from our investigative work
We see recurring themes in our investigative work across the healthcare sector. If your organisation is struggling with any of the following, our expert investigators can provide the clarity and evidence needed to prevent future harm:
- Organisations ignoring red flags. From experience we know that serious incidents are rarely isolated events.
- Senior managers being disconnected from “floor-level” staff, causing them to be unaware of organisational challenges.
- Poor communication and interpersonal friction. These are high-risk factors for clinical errors.
- Poor governance causing internal reporting systems to only tell part of the story, missing underlying systemic failures.
- A poor organisational culture undermining incident reporting and learning as staff don’t feel safe to speak up.
We help you identify these patterns before they escalate into a major safety breach, allowing you to build a more resilient, safety-first organisation. Connect with our senior team today to see how we can support your specific challenges.
Serious incident investigator services
The experience gained from our incident investigator services means we are 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.
Verita’s serious incident investigation 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.
What Our Clients Say About Us
“I wanted to thank the team at Verita for their outstanding work overseeing the NHS investigation reports, and for the excellent Lessons Learned Report – we appreciate your contribution to this important work.”
“Ed and the team at Verita provided a thorough and objective assessment of some difficult cases for us, helping us identify areas for improvement, meet a commitment to openness and engage the families involved. It made a real difference in addressing some long standing difficult issues.”
Case Study: Providing Objective Clarity in Social Care Incidents
Investigating serious incidents in care home settings requires a balance of clinical expertise and sensitivity. In this case, Verita stepped in to investigate the treatment of a patient after internal reviews failed to satisfy the family’s concerns.
By benchmarking internal practices against national standards and clinical evidence, we were able to confirm that the care provided was appropriate and robust.
The review and our findings demonstrates how an objective viewpoint provides organisations with the independent assurance needed to resolve sensitive disputes and protect its reputation.
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.
Our Clients
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Our Serious Incident Investigation Insights
Serious Incident Investigation FAQs
Verita is often asked to help when an incident has come to the attention of the executives and non-executives of an organisation. Other prompts for involving us include: serious complaints, media attention, MP involvement and regulator concerns.
The Verita team is familiar with PSIRF and its application in healthcare. However, most of our investigative work is conducted using the Verita operating framework. Where we carry out an internal investigation in accordance with an organisation’s own policy, then we follow the requirements of the internal policy.
Our investigations come in all sizes. Some can be conducted in a few weeks. Others may take six months or so to complete. The factors that determine the timescale are: complexity of the matter to be investigated; number of people to be interviewed; volume of documentation; and the type of report required. Investigations are complex undertakings, and we ask all clients to appoint someone senior to liaise with us. This support helps keep an investigation on track.
We contact families with the agreement of the organisation, and they are often the first people we meet. We see families several times during an investigation. We meet them at the completion of our work to talk through our report.
We write to those staff we wish to interview and provide them with our terms of reference and written guidance about being interviewed. All staff can choose to be accompanied to their interview by a friend and/or adviser. All interviewees will receive a typed record of their interview. They can amend it before signing it off.
Our investigative method is tailored to the assignment. Our approach is to establish the facts, making findings and conclusions. Experience shows that explanations for incidents are almost always multifactorial.
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