ed marsden

2. IMPROVEMENT THROUGH INVESTIGATION
The role of independent
investigations, including parallel
investigations
Ed Marsden, managing partner, Verita
National Healthcare Conference, Dublin 2015

3. IMPROVEMENT THROUGH INVESTIGATION 3
Recent investigations

4. IMPROVEMENT THROUGH INVESTIGATION 4
Aim
• What are the triggers?
• What are the benefits and risks
• What are the implications of parallel investigations –
particularly focusing on an investigation being
carried out by the police?

5. IMPROVEMENT THROUGH INVESTIGATION 5
What is an independent investigation?
• Evidence based review with details gathered from a
wide range of sources
• External, impartial investigators
• Objective findings
• Lack of pressure from commissioners

6. IMPROVEMENT THROUGH INVESTIGATION 6
What are the triggers
• Severity of the outcome
• The law
• Degree of public interest
• Capacity and capability
of an organisation to
investigate itself
• Views of families or the
public
• Likely scrutiny of
outcome
• An organisation’s own
policy
• It’s the right thing to do

7. IMPROVEMENT THROUGH INVESTIGATION 7
“The problem with free
elections is that you can’t
predict the outcome.”
What are the benefits and risks?

8. IMPROVEMENT THROUGH INVESTIGATION 8
Benefits
• A thorough and persuasive investigation that sheds light on
a complex matter
• A full and truthful exposition of facts
• Victims, relatives and staff feel engaged and heard
• A powerful set of recommendations to support
improvement and change
• An independent account that can be published
• Interested parties given a truthful and unbiased account

9. IMPROVEMENT THROUGH INVESTIGATION 9
• The investigation report
doesn’t convince
• The investigation is
procedurally unsound
• The outcome comes as
a surprise
Risks

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Parallel investigations
• There is nothing in UK law that says investigating a
crime comes before investigating a patient safety
incident
• An MoU signed in 2006 gives healthcare providers the
framework to ensure effective working of parallel
investigations
• Two good reasons for running parallel investigations:
• Patient safety
• Relatives and families

11. IMPROVEMENT THROUGH INVESTIGATION 11
Summary
• Independent investigations are likely to gather even
more traction in organisations working to the open
disclosure policy.
• Every organisation should know when and how to
commission an independent investigation.
• Seek advice before commissioning.

12. IMPROVEMENT THROUGH INVESTIGATION 12
Action
Are you clear about the circumstances that
would trigger such an investigation?

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Partnership with British Medical Journal (BMJ)
• Aimed at delivering patient safety programmes
• Based on our investigative experience and BMJ's
quality improvement programme (QIP)
• Consultancy & online tools to guide interventions
• Currently working with a UK hospital on oxygen
therapy & falls

14. IMPROVEMENT THROUGH INVESTIGATION 14

15. IMPROVEMENT THROUGH INVESTIGATION
The role of independent
investigations, including parallel
investigations
www.verita.net/Dublin-conference