Management of investigations and serious incidents policy

The purpose of this policy is to ensure that risks associated with serious incidents are identified and managed in accordance with best practice and in line with the expectations of the NHS Resolution, the Health and Safety Executive, the Care Quality Commission, NHS England and NHS Improvement, Clinical Commissioning Groups and the public.

Publication date:
01 September 2019
Date range:
September 2019 - September 2022

7. Just culture guide

7.1

The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame. Supporting staff to be open about mistakes allows valuable lessons to be learnt so the same errors can be prevented from being repeated. The Just Culture Guide was developed
as a tool in promoting cultural change.

7.2

The guide was developed by NHS Improvement in March 2018 and is used to support a conversation between managers about whether a staff member involved in a patient safety incident requires specific individual support or intervention to work safely.

7.3

It asks a series of questions that help clarify whether there truly is something specific about an individual that needs support or management versus whether the issue is wider, in which case singling out the individual is often unfair and counter-productive. It also helps reduce the role of unconscious bias when making decisions and will help ensure all individuals are consistently treated equally and fairly.

7.4

The guide should not be used routinely. It should only be used when there is already suspicion that a member of staff requires some support or management to work safely, or as part of an individual practitioner performance/case investigation. The guide does not replace the need for patient safety investigations as the aim of RCA investigations is
system learning and improvement.

7.5

A just culture guide can be used at any point of an investigation, but the guide may need to be revisited as more information becomes available. It does not replace HR advice and should be used in conjunction with organisational policy. The guide can only be used to take one action (or failure to act) through the guide at a time. If multiple actions are involved in an incident they must be considered separately.

Just culture guide

Key: 'Q' = Question

Q1. Deliberate harm test

  • 1a. Was there any intention to cause harm?

    • If the answer to 1a. is 'Yes':

      Recommendation: Follow organisational guidance to appropriate management action. This could involve: contact relevant regulatory bodies, suspension of staff and referal to police and disciplinary process. Wider investigation is still needed to understand how and why patients were not protected from the actions of the individual. End here. 
    • If the answer to 1a. is 'No':

      Go to Q2.

Q2. Health test

  • 2a. Are there indicators of substance abuse?

    • If the answer to 2a. is 'Yes':

      Recommendation: Follow organisational substance abuse at work guidance. Wider investigation is still needed to understand if abuse could have been recognised and addressed earlier. End here.
    • If the answer to 2a. is 'No':

      Go to 2b.
  • 2b. Are there any indications of physical ill health?

    • If the answer to 2b is 'Yes':

      Recommendation: Follow organisational guidance for health issues affecting work, which is likely to include occupational health referral. Wider investigation is still needed to understand if health issues could have been recognised and addressed earlier. End here.
    • If the answer to 2b is 'No':

      Go to 2c.
  • 2c. Are there indications of mental ill health?

    • If the answer to 2c. is 'Yes':

      Recommendation: Follow organisational guidance for health issues affecting work, which is likely to include occupational health referral. Wider investigation is still needed to understand if health issues could have been recognised and addressed earlier. End here.
    • If the answer to 2c. is 'No':

      Go to Q3.

Q3. Foresight test

Note: If the answer is 'No' to the below three questions (2a, 2b and 2c), then go to Q4. 

  • 3a. Are there agreed protocols/accepted practice in place that apply to the action/omission in question?

    • If the answer to 3a is 'Yes':

      Go to 3b. 
    • If the answer to 3a is 'No':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 
  • 3b. Were the protocols/accepted practice workable and in routine use?

    • If the answer to 3b is 'Yes':

      Go to 3c. 
    • If the answer to 3b is 'No':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 
  • 3c. Did the individual knowingly depart from these protocols?

    • If the answer to 3a is 'Yes':

      Go to Q4.
    • If the answer to 3a is 'No':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 

Q4. Substitution test

Note: If the answer is 'Yes' to all of the below questions (4a, 4b and 4c), then go to Q5.

  • 4a. Are there any indications that other individuals from the same peer group, with comparable experience and qualifications, would behave in the same way in similar circumstances?

    • If the answer to 4a. is 'Yes':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 
    • If the answer to 4a. is 'No':

      Go to 4b. 
  • 4b. Was the individual missed out when relevant training was provided to their peer group?

    • If the answer to 4b. is 'Yes':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 
    • If the answer to 4b. is 'No':

      Go to 4c. 
  • 4c. Did more senior members of the team fail to provide supervision that normally should be provided?

    • If the answer to 4c. is 'Yes':

      Recommendation: Action singling out the individual is unlikely to be appropriate. The patient safety investigation should indicate the wider actions needed to improve safety for future patients. These actions may include, but not limited to, the individual. End here. 
  • If the answer to 4c. is 'No':

    Go to Q5. 

Q5. Mitigating circumstances

  • 5a. Were there any significant mitigating circumstances?

    • If the answer to 5a is 'Yes':

      Recommendation: Action directed at the individual may not be appropriate, follow organisational guidance, which is likely to include senior HR advice on what degree of mitigation applies. The patient safety incident investigation should indicate the wider actions needed to improve safety for future patients. End here. 
    • If the answer to 5a is 'No':

      Recommendation: Follow organisational guidance for appropriate management action. This could include individual training, performance management, competency assessments, changes to role or increased supervision and may require relevant regulatory bodies to b contacted, staff suspension and disciplinary action. The patient safety incident investigation should indicate the wider actions needed to improve safety for future patients. End here.