Investigation
Recommendations related to investigation
Tag overview
recommendation across 16 inquiries
Across 16 inquiries
Tagged Recommendations
Regular updates on complaint progress
Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.
Staffing review in safeguarding investigations
Consideration of staffing (including skill mix as well as total numbers) should be a mandatory part of safeguarding investigations in all settings.
PSNI investigation file review processes
PSNI needs to improve its processes for the review of live investigation files, and have an effective escalation process when progress is delayed. PSNI should consider how it assures the …
Local authority security breach investigation
There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority …
Implementation of Operation Soteria
By March 2026, the Home Office, working with the National Police Chiefs' Council, and the National Centre for Violence Against Women and Girls and Public Protection, should agree plans for …
Update healthcare complaints handling guidance
The Home Office must review and update Detention Services Order 03/2015: Handling of Complaints to ensure that appropriate guidance is given to healthcare providers on the investigation and handling of …
Improve Professional Standards Unit investigation procedures and training
The Home Office must update Detention Services Order 03/2015: Handling of Complaints to clarify that, in investigations carried out by the Professional Standards Unit into allegations of serious misconduct against …
Update whistleblowing DSO with anonymous reporting mechanisms
The Home Office must update Detention Services Order 03/2020: Whistleblowing – The Public Interest Disclosure Act 1998 to require contractors that run immigration removal centres to: have a whistleblowing policy …
Metropolitan Police investigation into Lambeth Council
The Metropolitan Police Service should consider whether there are grounds for a criminal investigation into Lambeth Council's actions when providing information to the coroner about the circumstances surrounding LA-A2's death.
Written questions as alternative to face-to-face IOPC interviews
Consideration should be given to the introduction of a practice requiring, as an alternative to a face-to-face interview, the submission of a list of questions for written answer within a …
Forensic analysis of Daniel Morgan's diary
The Panel has received advice from an independent forensic science expert it consulted, Dr Kathryn Mashiter that useful work could still be carried out on this document. It therefore recommends …
DNA samples from Police Officer Z31's relatives
The Panel recommends that the Metropolitan Police consider the desirability and explore the possibility of obtaining samples of DNA from former Police Officer Z31's relatives, to compare it with the …
Review HOLMES system resources
The HOLMES system is both an investigative tool and a quality assurance mechanism, but it requires significant resources if it is to be used properly. The Panel recommends that the …
Rapid Response Capacity
The Northern Ireland Civil Service should have regard to best practice elsewhere about how to respond effectively when serious problems emerge, such as those that did so with the non-domestic …
Suspension during investigation
We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension …
Age-Appropriate Hospital Settings
Health and Social Care ('HSC') Trusts should publish policy and procedure for ensuring that children and young people are cared for in age-appropriate hospital settings.
CEO Responsibility for Investigations
Compliance with investigation procedures should be the personal responsibility of the Trust Chief Executive.
Independent SAI Investigation
The most serious adverse clinical incidents should be investigated by wholly independent investigators (i.e. an investigation unit from outside Northern Ireland) with authority to seize evidence and interview witnesses.
Non-Cooperation as Disciplinary Offence
Failure to co-operate with investigation should be a disciplinary offence.
Separation of Investigation and Litigation
Trust employees who investigate and accident should not be involved with related Trust preparation for inquest or litigation.
Family Involvement in SAI Investigations
Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all …
Multi-Disciplinary Peer Review
Investigations should be subject to multi-disciplinary peer review.
Investigation Team Reconvening
Investigation teams should reconvene after an agreed period to assess both investigation and response.
Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
SAI Investigator Training
Training in SAI investigation methods and procedures should be provided to those employed to investigate.
Involve patients and relatives in incident investigation
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious …
Shooting Incident Policy
A Shooting Incident Policy should be drafted which is achievable in practice in Theatre, which is compliant with Article 2 of the ECHR and which enables the ascertainment of the …
Internal investigation independence
Health Boards should ensure that a non-executive Board member or a representative from internal audit takes part in an Internal Investigation of the kind instigated by NHSGGC.
Lowering barriers
Patient feedback which is not in the form of a complaint but which suggests cause for concern should be the subject of investigation and response of the same quality as …
Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Investigations
Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward …
Nursing and Midwifery Council Investigation of systemic concerns
The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give …
Investigation Powers
The Board, being an independent self-regulatory body, should have authority to examine issues on its own initiative and have sufficient powers to carry out investigations both into suspected serious or …
Ring-fenced Enforcement Fund
A new regulatory body should establish a ring-fenced enforcement fund, into which receipts from fines could be paid, for the purpose of funding investigations.
Death in Custody Checklist
JDP 1-10 should include a simple checklist for actions on a death in custody. Where there is a death in custody, particularly one that is sudden or unexplained, prompt checks …