Lancashire Care Foundation Trust: Improving value and patient safety through the creation of a team of specialised serious incident investigators

Lancashire Care FT set up an investigations and learning team, in response to concerns that the trust was not effectively learning from serious incidents. This central team now undertakes all trust serious incident investigations.

Its aim is to undertake impartial, high quality serious incident investigations, engaging and supporting all people involved, and to improve learning at the trust from these situations. The scheme is cost neutral, as it releases other staff from carrying out investigations, and team members undertook a post-graduate level course in serious incident investigation to improve their knowledge and skills.

Service users and their families who had been involved in serious incidents worked with the trust to select the staff members and helped develop story boards for staff training. The outcome has been high levels of satisfaction with investigations from patients, family and staff, and improved quality of investigations – the quality and honesty of them has been remarked on by various coroners. Learning bulletins are shared through the trust’s weekly staff briefings.

Read a detailed case study about this project at HSJ Solutions  


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