Independent incident reviews

Investigating an incident (or a near-miss) can be a lot of hard work and when you’re doing it on top of all the other work you have, it can also take a long time.  The longer an incident review takes, the more unsettling it can be; services can appear to suspend while waiting for the outcome, staff lose motivation and patients can often detect something’s wrong.  It also takes longer to bring about change.  Sometimes, by the time the change is implemented, we’ve forgotten why it was needed in the first place – the context is long forgotten.

So, having someone independent to review and draw lessons from an incident can have a lot of advantages: 

  • The impartiality of an independent reviewer means they’re likely to consider some factors that hadn’t occurred to you
  • If the independent reviewer is experienced in your field (which they absolutely should be) you’ll have the benefit of what they’ve learned from other services too, and recommendations will be contextually relevant and realistic
  • It’s less personal and easier for relationships to move on after the review if it’s been written by someone independent
  • Witnesses often disclose information to someone independent that they wouldn’t say directly to their employer, so you get a fuller story
  • The review can probably be executed more quickly - which means you can learn and move on
  • Learning can be quickly translated into a project plan so you can make the changes you need to while they feel relevant.
Inviting someone else into your service also says to other people ‘we’re willing to open up to learning’. While I was head of mental health and homicide enquiries for a strategic health authority, I was always less likely to commission an Independent Homicide Inquiry into a Trust if, in their own internal review, they’d included external peers/specialists. It showed organisational maturity and a willingness to learn.
— Liz Allen