Methodology for investigation
1. Gather and review all relevant information, e.g.
service user notes/case file;- relevant policies / procedures / standards;
- other records (such as training records, service/maintenance records, staff rotas, electronic information);
- engage with people involved (such as staff, complainant, carers/family, other agencies).
2. Information mapping – involves ‘ordering’ the information gathered into a useful way – sequence of events. Techniques which can be used, e.g.
- Narrative Chronology, i.e. what happened in date/time order. This provides one account of the complaint under investigation.
- Timeline – this is a chronology of information, giving precise dates/times with each step of the critical path in a box and each box is linked by an arrow indicating the direction of the time.
- Tabular Timeline – similar to above but recorded in a table.
- Time person grid – this is helpful for close analysis of concentrated time periods when you need to understand who was doing what and where.
3. Problem identification and prioritisation – The chronology will naturally generate questions that need answers. Some may be regarding the chain of events, others will be ‘why?’ questions. Problems should be categorised into Care Delivery Problems (CDP) and/or Service Delivery Problems (SDP).
- CDP – a problem related to direct provision of care, usually actions or omissions by staff (active failure) or absence of guidance to enable action to take place (latent failure), e.g. failure to monitor, observe or act; an incorrect decision (with hindsight); not seeking help when necessary.
- SDP – acts and omissions identified that are not associated with direct care provision. They are generally associated with decisions, procedures and systems that are part of the whole process of service delivery, e.g. equipment failure.
4. Analysis – The need to prioritise the problems; confirm that no critical issue has been overlooked; analyse the problems and issues identified; establish their ‘root’ causes i.e. the fundamental issues.
- Group problems together to identify any emerging themes and decide which need further exploration.
- Key part of the analysis is to identify the key contributing factors lying behind each problem.
- The 5 ‘W’s’- what happened? When? Where? Why? Who? What can we learn? and What changes should be made?
5. Recommendations and reporting – once the issues and problems have been analysed and ‘root’ causes established, the recommendations should be developed to prevent another complaint or incident of the same type happening again.
6. Write report – in line with local guidance or format which should be based on Health and Social Care (HSC) Regional Template and Guidance for Incident Investigation/Review Reports (September 2007) available on the Department of Health website
7. Draft a response- to the complainant from the Chief Executive (or delegate) of the HSC Trust or Senior Partner in the FPS.