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System Failures
System failure reports identify institutional or organizational errors that contributed to a fatality or serious incident. These assessments look beyond individual clinical performance to evaluate whether flawed protocols, inadequate staffing, or failed communication channels created the conditions for a preventable death.
Overview
When this report is required
- Institutional Negligence Inquests occur when multiple errors across a department suggest a systemic rather than individual failure
- Regulation 28 Reports are supported by expert evidence to help Coroners issue “Prevention of Future Death” notices to organizations
- State Custody Inquiries are necessary to investigate whether prison or police protocols failed to protect a vulnerable individual
- Multi-Agency Reviews assess whether the lack of information sharing between different trusts or authorities led to a fatal outcome
What the expert assesses
- Adequacy of organizational protocols
- Staffing levels and competency frameworks
- Communication and hand-over procedures
- Equipment availability and maintenance logs
- Quality assurance and audit compliance
Report specification
| Element | Detail |
|---|---|
| Assessment Setting | Desktop Review / Institutional Audit, Remote |
| Court Acceptance | Coroner’s Court, Public Inquiry |
| Compliance | CPR Part 35 |
CPR Part 35 Compliant
Digital Delivery
Urgent Instructions
Specialist expertise
Clinical Governance Experts
Nursing Leads
Healthcare Managers
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.