Service 05 / 09
Incident Investigations & Root Cause Analysis
Independent investigations that find causes, not culprits.
Overview
When something goes wrong in care, families deserve answers and organisations deserve the truth. We conduct independent, systems-based investigations that go beyond individual error to uncover the latent conditions, design flaws and organisational factors that allowed harm to occur.
Our investigators are trained in human factors and experienced in Patient Safety Incident Investigations under PSIRF, duty of candour, and compassionate engagement with families and staff throughout the process.
What we deliver
- Independent serious incident investigations
- Root cause analysis and systems-based reviews
- Duty of candour and family engagement support
- Thematic reviews and organisational learning reports
- Investigation skills mentoring for internal teams
The outcome for you
Credible findings that withstand external scrutiny
Learning that prevents recurrence, not blame
Families and staff treated with dignity throughout
Questions, answered
Frequently asked questions
Why use an independent investigator instead of our own team?
Independence brings credibility — with families, coroners, commissioners and regulators — and freedom from internal assumptions. It also adds specialist human-factors expertise and capacity at exactly the moment your own team is under most pressure.
Will an investigation blame our staff?
No. We work in a systems tradition: we examine how the environment, equipment, staffing and processes shaped events. That is both fairer to staff and far more effective at preventing recurrence.
How do you involve families in an investigation?
With their consent, we meet them early, invite their questions, keep them updated throughout and share findings in plain language. Compassionate engagement is not separate from a rigorous investigation — it is part of one.
Consultation enquiry
Let's make your organisation measurably safer.
A confidential, no-obligation conversation with a senior consultant. We respond to every enquiry within one working day.