Appendix 1 Overview of the investigation process

This flowchart provides a brief overview of a systems investigation for investigating serious incidents in the NHS. It requires a ‘questioning attitude that never accepts
the first response’, and uses recognised tools and techniques to identify:

• The problems (the what?) including lapses in care/acts/omissions; and
• The contributory factors that led to the problems (the how?) taking into account the environmental and human factors; and
• The fundamental issues/root cause (the why?) that need to be addressed.

Overview of serious incident management process

Key: Q = Question.

Note: For sections 2, 3, 4 and 5 the following applies:

• Opportunities for feedback and learning identified and information shared
• Support and involve those affected (including patients, victims and their families and staff)

1. To be done within two working days:

Top of chart begins: 

• 1a. Incident occurs

• 1b. Report on LRMS/NRLS and to other bodies such as safeguarding lead as applicable.

• 1c. Q: Is it a serious incident?

  • If 'No':

    • Manage in line with local risk management policy and
    • engage with those affected. 

  • If 'Unknown':

    • Review and discuss with commissioner
    • Return to 1c. 

  • If 'Yes':

    • Engage with those affected
    • Notify other stakeholders as required e.g. safeguarding, CQC, TDA etc.
    • Report on STEIS
    • Go to section 2. 

2. To be done within three working days

• 2a. Complete initial review and submit to commissioner where possible this should be the provider's lead commissioner who can liaise with others as required. This should be outlined in the RASCI model.

• 2b. Confirm level of investigation required. 

• 2c. Go to section 3.

3. 60 working days or 6 months for independent investigation

• 3a. Lead investigator identified. Team established. Terms of reference set. Management plan established

• 3b. Undertake the investigation

  • Gathering and mapping information
  • Analyse information
  • Generating a solution

• 3c. Submit final report and action plan

• 3d. Go to section 4

4. To do within 20 days

• 4a. Commissioner (with relevant stakeholders) undertakes a review of the final report and action plan and ensures it meets requirements for a robust investigation (see appendix B). Feedback given to provider. 

5. Ongoing

• 5a. Commissioner closes investigation and confirms timescales/mechanism for monitoring the action plan where action/improvements are still being implemented. 

End of flowchart