Find what allowed the incident to happen.
Naming the immediate mistake rarely explains why the situation arose, or what would stop it arising again. We establish what happened from the evidence and the people involved, then examine the instructions, information, supervision and decisions that shaped the work, and recommend changes with named owners.
When this can help.
How we work.
Build an evidence-based timeline from records, observations and accounts of the people involved. Separate what is established from what remains uncertain.
Examine the information, instructions, equipment, supervision and organisational decisions around the event, including how they interacted.
Set out practical recommendations, who needs to act and how the organisation can check whether the changes have been implemented and are working.
What you receive.
The proposal confirms the outputs, boundaries and responsibilities for your engagement.
Scope, and what this is not.
Our principal designed and led systems analyses of incidents in residential care and hospital work. Two published reports describe the work. Read the case and access the public reports →
The questions clients ask first.
The report describes relevant actions and the evidence supporting its findings. We agree identification and confidentiality arrangements at the outset, taking applicable obligations into account; anonymity cannot be promised in every context.
Contact us to check availability. Preserve evidence and follow your organisation’s emergency and notification arrangements without waiting for a reply. Start date, access and scope must be agreed.
Coaching can be included in an investigation, with responsibilities and participants agreed in the scope. It is not automatically included in every review.
Optional: the method behind the work
The method, for anyone who wants it.
Depending on the question and evidence, methods may include ActorMap, AcciMap and STAMP. They help examine the people and organisations involved, connections between contributing conditions, and intended checks or feedback. We also ask what information and pressures shaped a person’s decision at the time, rather than judging it only with hindsight.