100380865 Thesis 2nd submission

Purpose
Serious incidents within the NHS Healthcare setting are adverse events where the
consequences to patients, families and carers, staff or organisations are so significant or the
potential for learning is so great that an investigation is instigated.
There have been several highly publicised inquiries in NHS England over recent years, related
to the poor quality of patient care that has resulted in significant and severe harm. These
inquiries suggest that learning from serious incident investigations is not occurring.
Methodology
A combination of archival research and case study approaches that share phenomenology
characteristics were the methodological approaches to conducting a critical review of the
serious incident management and investigation processes within NHS England health care
settings, to comprehensively understand the issues and core problems. This study focused on
an ambulance service and commissioning organisation within NHS England.
Three focus groups were conducted to explore their experiences of the serious incident
management and investigation process. Ambulance service historical investigation reports
were reviewed to explore the types of serious incidents, root causes and recommended actions
taken to address the root cause.
The data was thematically analysed and Goldratt’s Thinking Process Tools were applied to the
analysis to diagnose the issues within the serious incident management and investigation
process. The Transition Tree from the Thinking Process Tools was combined with the DMAIC
service improvement tool to create the theoretical diagnostic and service improvement tool to
help improve the management and investigation of serious incidents.

Findings
The key issues identified within the serious incident management and investigation process
were:
• Constraints – time and resource to undertake thorough investigations.
• Root Cause identification – difficulty to identify root cause resulting in either an
incorrect root cause or multiple root causes.
• Actions - actions and action plans do not always resolve the root cause and prevent
repeated avoidable recurrences.
• Process – scoping what the serious incident is and how it will be investigated.
• Focus – the investigation reports do not always specifically focus on the actual serious
incident and the outcome.
• Learning - occurs at an individual level rather than at an organisational level.
• Training – investigator skills and experiences needed to correctly apply the root cause
analysis tool in a serious incident investigation.
The core problems were identified as: process for scoping serious incident investigations, focus
and training.