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


Most Serious Incidents, when investigated well will determine system errors rather than individual errors. 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. This must be used in investigations if considered that there may be a managerial investigation.


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.


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.


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.


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.