Learning from serious incidents in NHS acute hospitals: a review of the quality of investigation reports

Document type
Corporate author(s)
Care Quality Commission
Care Quality Commission
Date of publication
1 June 2016
Health Services
Social welfare
Material type

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This review includes a sample of 74 investigation reports from 24 NHS acute hospital trusts, which represent 15% of the 159 acute trusts in England. 

An assessment framework based on NHS England’s Serious Incident Framework was used, with associated guidance, templates and tools.

The review identified the following opportunities for improvement:

  • Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
  • Routinely involving patients and families in investigations.
  • Engaging and supporting the staff involved in the incident and investigation process.
  • Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
  • Using human factors principles to develop solutions that reduce the risk of the same incidents happening again.

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