We carry out up to 30 investigations a year – they must have occurred in England, within NHS funded care and after 1st April 2017
for potential investigations can be shared by individuals, groups or
organisations. The decision to start an investigation could relate to a single
event, a series of events or an issue discovered through current, ongoing
All of our
cases are logged and stored on database and become part of a process of review
to help identify themes and patterns of safety issues over time.
effective learning comes from thorough investigations that produce meaningful
recommendations to share at a national level. By not attributing blame or
liability and asking the right questions we reduce the risk of something
similar happening in the future.