Case Studies

Reviewing a cluster of seven incidents within a team

Reviewing a cluster of seven incidents within a team

Reviewing a cluster of seven incidents within a team banner icon


There were two issues for the Trust; a preference for an independent investigation because of the sensitivities of the case and a review of the organisational response prior to the incidents occurring in order to determine what needed to change.

The Issue

X Community Health Trust had recently had a cluster of seven serious incidents within one team. Alongside the investigation of the incident, as a second part to the review, the Trust wished to engage the services of an external company to understand the organisational response leading up to the incidents occurring. This was to ascertain if there are any system changes which could be made to prevent recurrence.

Our Approach

Niche allocated a team of three people to investigate two main themes; firstly, how the Trust had approached incident investigation and lesson learning from these 7 incidents, and secondly how the Trusts governance processes had worked as the incidents occurred.

Niche developed an investigation schedule that set out what the team wanted to look at and when. The investigation team were based on site at the Trust for a few days whilst documents were reviewed and people were interviewed. The team also observed a committee in operation and carried out a series of telephone interviews. The people involved in the process were informed that their comments would be protected as confidential, unless there was a whistle-blowing or public interest issue. The purpose of this review was to obtain learning and ensure that changes could be made to prevent or minimise the chance of re-occurrence.

The outcome of the project/ review

The final product was a report that set out findings, facts and contributory factors. In summary, it reported on:

  1. opportunities for intervention that may have prevented patient harm
  2. organisational systems
  3. Board monitoring and assurance.

In summary, the review found that the cluster of incidents could have been prevented.

The systems in place at the time did not provide adequate assurance of the quality at the point of care. The escalation systems to raise these issues to the Board were not fit for purpose, in part due to the absence of a whole picture reporting on each service, but also because they did not focus on the right areas. There was a lack of recognition that the initial incident would lead to significant patient harm by middle and senior operational managers, and a subsequent slowness to act.

The recommendations focused on revision of the quality committee’s terms of reference, a change in senior manager focus and the further development of a quality trigger tool to bring the right quality intelligence to the Board.

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