We carry out up to 30 investigations a year – they must have occurred in England within NHS funded care and after 1st April 2017
Any issues for potential investigation can be shared by patients, family members, carers, concerned members of staff, as well as providers and regulations. Our decision to start an investigation could relate to a single event, a series of events, or even an area we identified through current investigations.
Every case is assessed against our criteria. Even if it doesn’t meet those requirements, we are keen to always look at the broader picture. This means that every case is logged in our data base and is regularly reviewed. Data and information are crucial to improvement, as it will help us to identify consistent themes and emerging patterns of safety issues over time.
We believe the most effective learning can be drawn from thorough investigations and produce meaningful recommendations that are shared at a wider level. By not attributing blame or liability, asking the right questions, and gaining different perspectives we can reduce the risk of something similar happening in the future.