Patient Safety and Serious Incident Responses

This step-by-step guide takes the reader through the complex process of investigating serious incidents in health, social care, and criminal justice environments, acknowledging differences of culture and context that shape an investigation. Taking a multi-disciplinary approach, Part 1 begins by exploring the key principles of investigation, including ethical and legal perspectives, the involvement of families and carers, and being aware of unconscious bias, among other issues. Part 2 outlines in detail the conduct of investigations, from planning to processing the findings, before moving on to Part 3, carrying them out in diverse settings. Further chapters then look at investigating within diverse environments before moving on to to Part 4 which deals with reviewing and analysing the evidence collected and writing up the investigation. This final part also examines the pivotal issue of learning from the investigation and disseminating the report. The inclusion of case studies, models of good practice, and vignettes enables the reader to view each stage of the process in context and drive the transformation of practice. This practical resource is designed to support health and social care professionals who undertake investigations as part of their role, including nurses, allied health practitioners, social workers, doctors, and psychologists, as well as military personnel and law enforcers. It is an essential companion.

Alison Elliott is a Senior Lecturer at the University of Central Lancashire and Programme Lead: Offender Personality Disorder Programme. Karen M. Wright is Professor Emerita at the University of Central Lancashire, practicing psychotherapist, Chair of an NHS research Ethics Committee, and registered nurse.

Acknowledgements Table of figures Editors & Contributors Foreword Introduction PART 1. Principles of investigation 1: Understanding and Avoiding Unconscious Bias 2: To Debrief or not to Debrief 3: The Theoretical and legal principles of formal investigations 4: Family engagement - why it matters PART 2: Conducting the investigation. 5: Planning Investigations 6. Individual investigative Interviews 7: Managing Interpersonal dynamics, and issues with group interviews 8: Processing, reviewing and analysing material PART 3 : Investigating in diverse environments. 9: Managing Diversity and Vulnerability 10: Serious incident investigations involving children and young people 11: Investigations in the custodial setting - practical advice 12: Investigating within the military context 13: Fitness to Practice Investigations 14: Managing Organisational Dynamics PART 4: Post- investigation reporting, learning & development 15: Approaches to managing information post investigation 16: How to present a report & the executive summary 17: 'Cautionary tales: investigations - the effects on staff involved' 18: The coroner's inquest and attendance to an inquest hearing 19: Closing the loop: Creating learning from the incident Glossary of Terms.