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Root Cause Analysis
Root Cause Analysis (RCA) reports provide a structured investigation into the underlying factors of a serious clinical incident or fatality. Rather than focusing on superficial errors, these assessments identify the fundamental “root” causes to prevent recurrence and satisfy the evidentiary requirements of an inquest.
Overview
When this report is required
- Serious Incident Investigations occur following an unexpected death to determine the primary causal factors
- Clinical Governance Reviews are required by legal teams to evaluate if institutional safeguards were fundamentally flawed
- Article 2 Inquests necessitate a deep-dive analysis into state-controlled environments to identify systemic vulnerabilities
- Post-Incident Litigation uses RCA evidence to establish whether a specific failure was an isolated event or a structural certainty
What the expert assesses
- Primary causal and contributory factors
- Human factors and ergonomic influences
- Environmental and equipment stressors
- Organizational and management hierarchy
- Effectiveness of existing risk-mitigation strategies
Report specification
| Element | Detail |
|---|---|
| Assessment Setting | Clinic, Desktop Review, Remote |
| Court Acceptance | Coroner’s Court, Public Inquiry |
| Compliance | CPR Part 35 |
CPR Part 35 Compliant
Digital Delivery
Urgent Instructions
Specialist expertise
Human Factors Experts
Clinical Governance Leads
Patient Safety Specialists
While these are the primary specialists engaged for this instruction type, please note that every case turns on
its own facts. Complex or multi-disciplinary cases may require a bespoke team of experts. Our case managers will
review your specific instruction to ensure the correct clinical match.