Investigation Services

Investigation, mentoring & QA service Using a Systems Based Approach

Kate and Jo have over two decades of experience in conducting high quality, complex investigations spanning different organisations, settings, and stakeholder boundaries

Some examples of the investigations we have completed over the last 20 years are as follows:

1. A thematic review of over 160 patient experiences spanning a 15-year period in a General Surgery Department. We worked with the General Medical Council during the review and the Royal College of Surgeons were also involved. This review attracted media attention. The review focused substantively on Human Factors and the culture of the organisation with regard to whistleblowing.

2. A multi-agency investigation into the death of a mental health service user in a fire on a locked mental health ward. The police, fire brigade and health and safety executive were also running parallel investigations. Our investigation focused on the service user’s residential placement, her detention, out of area placements, the impact of the smoking ban on service users and staff, organisational approach to risk assessments and searches.

3. We were commissioned to quality assure 12 Never Event investigation reports for a private healthcare provider. The cases covered dental surgery, anaesthetics, tissue viability, wrong size prosthetics, wrong site surgery and retained swabs. We provided comprehensive feedback to the client on improvements needed to their overall investigation process, policies and templates.

4. A maternity case involving the death of a baby. We looked at the care provided by the midwives, obstetricians, sonographer (NHS and private), community midwives and general practitioners. Our recommendations focused on human factors training and multi-disciplinary in-situ simulations.

5. The death of a service user in a new build/purpose-built home treatment house. We not only looked at the care provided but focused on the roles of the builders, architects and corporate redevelopment. We made recommendations about the national building guidelines for new build mental health units.

6. We investigated the death of a cardiac patient. In this case the patient was an inpatient in a hospital in one Trust, whilst the MDT which decided on the course of treatment fell under the umbrella of another Trust (which was a regional hub). We looked at how the relationship between these two organisations impacted on patient care.

7. We undertook an investigation into a delayed HIV diagnosis. The patient submitted a complaint. During the Trust’s investigation of the complaint part of the complaint was escalated and investigated under the Trust’s serious incident process. The patient was dissatisfied with the quality of the complaint response and the serious incident report. We were asked to quality assure both and re-investigate both. We met with the patient and produced an itemised list of 218 concerns, each one of which we addressed separately. Our 144-page report looked at the interface and lines of communication between multiple departments and agencies.

8. We undertook an investigation into the death of a service user on a locked mental health unit. We chaired the panel, which included the Chair of the Trust, the Medical Director, Psychologist, Community Psychiatric nurse, a Psychiatrist and a representative from NHS England. During our investigation we obtained evidence from the NMC regarding the relatively new role of nursing associate and the effect of COVID-19 on staffing on wards. We liaised with the police, pathologist and the CCG (regarding funding for out of placements). We considered the role of YouTube in the service user’s death. We worked with the family liaison officer to secure therapy for the service user’s step-daughter.

9. We have been involved in the review of a mental health service user’s death in the community. The case related to substance misuse. The investigation ran parallel to a safeguarding review and a police investigation into potential domestic violence.

If you would like to speak to us about how we can help you with an incident investigation please contact us here.

Also in this section:


Covering key moments of the investigation process and cover scoping, evidence collection, production of a timeline…

Quality Assurance

Providing you with a thematic review of a number of incident investigation reports, or critique on single investigation reports…

Independent Panel Members/Chairs

Available as both panel members and Chairs, we can add experience, rigour and independence to any investigation..


Medico-legal training e-learning courses