We carry out up to 30 investigations a year all occurring in England and after 1st April 2017.
investigation can be shared by organisations or individuals and our decision to
investigate could be a single event, a series of events or even something that
we find through an investigation.
Even if we
can’t investigate each case, we want to ensure that we’re looking at the
broader picture. This means that every case is logged into our database and
becomes an important part of helping us identify patterns of safety issues over
We believe that
the most effective learning will happen through the thorough investigations
that produce meaningful recommendations that can be shared at the widest level
attributing blame or liability and asking the right questions, we can focus our
efforts on reducing the risk of something similar happening in the future.