Thought Pieces

From investigation to action (and all of the stages in between)…

From investigation to action (and all of the stages in between)…

From investigation to action (and all of the stages in between)… banner image


On average, the NHS treats or engages with almost 1.3 million people each day (The King’s Fund, 2022[1]). Within these numbers, babies are born, cancer patients are treated, organ transplants are performed, counselling, psychiatry and inpatient services are provided for mental health conditions and palliative care is provided for the dying. It is a safety critical sector which needs the trust of the public.

But these are also often high-risk activities, and it is an unfortunate fact that occasionally there will be shortcomings in the care provided. Sometimes, however, these shortcomings have serious and even catastrophic effects. Where this happens, it is important that the serious incident management process clearly considers the following:

  • A broad scope investigation – A good quality investigation is the first step in ensuring that the action plan will have the desired impact. The investigation itself needs to have clear terms of reference, and there needs to be a degree of both independence and objectivity in shaping these. It is the role of the overseeing panel to ensure that all relevant lines of enquiry are investigated and reported back on fully.
  • Involving the Patient Safety team – The expertise of a good Patient Safety, or Clinical Governance team can really add value:
  • as a critical friend to challenge the quality of the actions and sources of assurance identified;
  • In identifying themes and trends in safety incidents. They will know if a similar action is being taken elsewhere in the organisation, and where efforts can be combined, or at least not duplicated; and
  • In the sharing of learning from the incident with other, relevant teams.
  • Factual accuracy checking and acceptance of findings– The investigation report needs to be shared at draft stage with the service, so that they have an opportunity to comment on any points of factual inaccuracy, but more importantly, to consider that the recommendations made will help to improve the service as those staff are best placed to know how actions can be delivered.
  • Define how success will be measured (‘sources of assurance’) at an early stage – (and focus on this in your action tracking). Managers and clinical leaders need to routinely ask themselves ‘so what?’. When chairing your governance meeting, focus on outcomes, not inputs from the action plan. If a policy has been changed, ask for demonstrable evidence of improvement.
  • See the action plan as a long-term tool – The best action plans will form part of a quality management system which sees quality goals planned, controlled, assured and standards ultimately improve. This is where serious incidents can truly be used as a source of learning, when over time, the additional focus, awareness and resource to deliver the action plan supports continuous quality improvement.

What do we tend to find in the action and learning phase?

In the last two years, Niche has undertaken over 50 quality assurance reviews, many of which have been undertaken following an independent (level three) investigation commissioned because of an inpatient death or mental health homicide; that is to say, ‘catastrophic harm’.

Once a robust investigation or review has taken place there is a critical moment where real change can occur. However, the team responsible for taking the actions forward are often already stretched with their caseload and fatigued (both mentally and administratively) by the investigation which can often take months (if not years in some cases) to conclude.

This important opportunity to make improvements following an incident is often rushed, lacking engagement from key individuals and teams. Actions can be seen as something to ‘get over and done with’, rather than a useful tool that can guide meaningful learning and quality improvement. The most common shortfalls we see in action plans are:

  1. Overly complex recommendations are accepted by the service, which either can’t be or haven’t been broken down into their component tasks for ease of understanding and to ensure clear tracking and ownership.
  2. Actions are not properly linked to the care or service delivery problems – Assuming a good quality investigation was undertaken, the care and service delivery problems should dictate the actions required. Too often, there is little ‘read-across’ between these and the action plan.
  3. Actions are not aligned to existing risks nor do they generate new risks – The fact that an action has been proposed suggests there is a deficit identified. Has this deficit been risk assessed and added to a register? Thus improving the chances of holistic monitoring.
  4. Conflating input with outcome – Around 50% of the action plans we see will have actions such as: “email ‘x’ staff group” or “communicate x to nurses.” Rarely do services define what the desired outcome of a task is, nor when an action has been completed successfully, embedded or sustained over time. There is usually insufficient attention given to how quality indicators, incident trends, staff and patient feedback can provide valuable sources of assurance.
  1. Human factors and behaviours are often ignored – It is easier for teams to focus on policy, process and tasks than issues relating to culture, dynamics or ways of working which often contribute to poor practice and incidents. These may be easier to implement, but alone won’t lead to a change in practice and can in fact increase the team’s apathy towards the action plan.
  2. Action plans are not assurance based – Actions should only be deemed ‘complete’ once checked for embeddedness. For assurance to be gained from an audit, it needs to be clear how the sample was decided, how the outputs of the audit were shared, what learning was gained and how ongoing compliance will be monitored.
  3. Policy changes – Some form of policy is almost always changed because of a serious incident investigation, but policies themselves mean little to most staff without the right communication, training and links to day-to-day procedures. Evidence of all of these things should be sought as assurance.
  4. The problem of monitoring – We often find that increased training and supervision is needed following an SI, but most NHS trusts lack the system to record and monitor this where the training is not statutory / mandatory. Thought needs to be given to this when designing the action plan.
  5. Sharing learning – This is always difficult in the health service, either in large, single site acute trusts with a vast range of services, or in geographically dispersed mental health, learning disability or community trusts, where sites are physically and sometimes culturally remote from each other. Action plans often omit sharing learning entirely, or else rely on a single communication, rather than tackling this in a variety of ways to reach the widest audience possible (for example, through one-to-one supervision, team debriefs, learning events, email, hard copy newsletters safety bulletins and multi-agency sessions where relevant).

By Danni Sweeney

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