Reports – Investigations NOTES

INVESTIGATION REPORTS – NOTES

CONTENTS

What is a report?p2

Types of reportsp2

Legal issuesp2

Principlesp3

Practicep4-9

Organizational issuesp10

References and bibliographyp11

WHAT IS A REPORT?

Evidence of events to which one was witness

A formal account or narration (Penguin dictionary)

A document containing FACTS and INFORMATION on a specific subject

A permanent written record

A formal document that will be read by others (Heller and Tindle 1998)

TYPES OF REPORTS

Craig LongstaffCreated 27.08.2002 – Revised 05.10.2018Page 1 of 11

Reports – Investigations NOTES

Investigatory

Persuasive

Explanatory

Historical

Suggestive/Proposal

Craig LongstaffCreated 27.08.2002 – Revised 05.10.2018Page 1 of 11

Reports – Investigations NOTES

LEGAL ISSUES

Civil Procedures Rules 1999

Criminal Justice Act 1988 s23-s28

Criminal Evidence Act 1968

Data Protection Act 1998

  • Confidentiality
  • Access
  • Storage and disposal

Defamation

  • Slander (spoken)
  • Libel (written)

Freedom of Information Act 2000

Human Rights Act 1998

  • Right to a fair trial
  • Right to privacy
  • Right not to suffer inhumane/degrading treatment (ANY detriment)

Protection from Harassment Act 1997

Public Interest Disclosure Act (PIDA) 1998 [Whistle-blowing]

PRINCIPLES

Use the NPSA’s Root Cause Analysis (RCA) and Incident Decision Tree (IDT) frameworks

Where possible, use report for learning and improvement not blame

Deliver/finish early (ahead of schedule) or on time

  • Under-promise, over-deliver
  • If you think it will take 2 weeks to complete:

Set timescale/limit of 3-4 weeks

Aim to submit at 2 weeks

Good quality

  • Character and ability of investigating and ancillary team/s is VITAL
  • Maintain confidentiality and privacy
  • Maintain anonymity where appropriate (exception rather than norm)
  • Neutral, impartial, independent, fair, objective, rational, thorough, effective, efficient, robust, rigorous and indisputable regards:

Process

Validity and “weight” of content and evidence

(accuracy; truthfulness; consistency; credibility; reliability

  • Reader friendly:

Readable

Lively and interesting/appealing

Simple; logical; clear to follow and understand what happened and issues

  • Format and content VITAL to overall impact

All writers/signers of statements are personally and publicly accountable

  • Report must be the author’s own
  • Always right in the knowledge that anyone could see/read it

(“Washington Post test”, Capt. Abrashoff in It’s Your Ship)

  • Always be independent, accurate, factual, objective, impartial and unbiased
  • Signing implies:

1) Ownership

2) Satisfaction and agreement regards EVERY aspect of content

3) Accountability

Nurses are bound by the NMC codes at all times

  • Rules of co-operation, accountability, confidentiality, etc

Format and content VITAL to overall impact

Busy managers should be able to see from the introduction and conclusion:

  • What the report is about (purpose)
  • Findings
  • Action plan (if any)

Most managers will only read (so concentrate on) the:

  • Introduction
  • Key headings
  • Conclusion
  • Recommendations
PRACTICE

Know, check and follow:

  • The law
  • Regulatory standards, codes obligations and requirements – Eg NMC, GSCC, CSCI
  • Organizational systems (policies; procedures; codes)

Seek independent and confidential advice, support and representation

Start the process immediately

  • From the point of investigation

Confirm:

  • Objective/s (remit; Term/s of Reference) and ensure fulfils
  • Audience and readers – Actual AND likely/potential

Plan and prepare:

  • Helps to focus and give direction
  • Who will read your report – Actual and likely/potential audience?
  • Objectives?
  • What makes a good report?
  • Develop a basic framework/outline first – themes and key headings
  • Mind map/s

Delegate parts of the report where necessary and appropriate

  • NB – NMC guidance regards delegation

Take, make and retain notes

Take your time

  • Do not be pressurized, put under duress, or denied rights to advice first
  • Think before you write
  • Give careful thought and consideration to what you say/write:

You will be questioned and challenged

You will need to justify and clarify

You will be held to account

It can rebound against you

  • DO NOT complete in the heat of the moment or when emotions high/raw:

You need to be dispassionate

Format

  • Format/present information using NPSA frameworks – IDT, RCA
  • Good quality paper:

Not on scraps, envelopes, tissue, cardboard, etc

  • On ONE side only:

Do not write or print ‘double-sided’

  • Margins: Left = 3cm; all others = 2.5cm
  • 1.5/double line spacing
  • Header/footer

? investigation report

Date/Name/Reference/Author

Number pages (page 'x' of 'y')

  • Paragraphs:

Number

Should be wider than they are long

  • “DRAFT” until final version
  • Version control – Version # (Eg Version 3)

Content

Preliminary investigation report

  • Whether the allegations appear (un)founded
  • What serious issues exist: Misconduct, competence, capability, performance, risk
  • Whether further, in-depth investigation required
  • What systems require invoking

Final investigation report

  • See template
  • Main issues/findings:

As per incident decision tree and root cause analysis

Proximal (near; immediate) AND distal

Actionable; Non-actionable

  • Appropriate and reasonably directed responsibility and accountability (fair blame)
  • What went well
  • What went wrong
  • Current systems (“the norm”)
  • Prioritised recommendations, (potential) improvements and solutions, and action to address/resolve issues
  • Routes of resolution and/or action

Generally

  • Use graphics to visualize
  • Use initials for names
  • Follow the basic principles of documentation and record-keeping:

See separate notes + Dimond 2005 pp 199-203

Legible – Typed

Grammar and spelling:

- Short sentences

- Write in the first person (“I”)

- Conversations/quotes: Verbatim; indent; use quotation marks and italics

- Use active not passive phrases Eg “they decided” not “it was decided”

- Avoid exclamation marks and underlining

- Avoid superfluous phrases Eg “at this Moment in time” (now) “in respect of” (about)

- Use your own words/words that you agree with, are sure of and understand

- Plain, every day English – see plain English campaign/website

- Avoid abbreviations and jargon

- Write on audience/likely readership’s level

- If necessary, provide a glossary (as appendage) to spell terms and/or define terms fully

- Avoid clichés, labels and stigma

Accurate, true, factual, objective:

- Keep to the facts as you know them (what actually took place)

- Include more facts than descriptions

- Only include first-hand information

(what you directly witnessed/took part in/were involved in)

- Substantiate/support/corroborate with indisputable evidence

- ‘In good faith’

- Avoid subjective Eg: Emotions

Personal opinions (unless an expert/professional witness)

Assumptions/value judgments

Hearsay (3rd party information told by others)

Include objective information even if it is likely to affect/expose an individual(s)

NB: PIDA 1998 (Whistle-blowing) issues

Relevant and concise (brevity):

- To the point; articulate; cogent

- Avoid overloading

- What would a stranger/outsider need to know?

- “Essential detail should not be sacrificed on the altar of brevity”(Dimond 2005 p201)

- Err on the side of inclusion if unsure but do not exaggerate

- What is left in can be omitted on the grounds of relevance, what is left out is left out for good

Clear (clarity)

- Organized

- Logical sequence/flow; chronological

- Unambiguous

- Readability

Consistent

Avoid:

- Omissions, exaggeration, trivialization/minimization

- Errors/mistakes

- Discrepancies, ambiguities, inconsistencies

- Weaknesses, loopholes

- Breaching confidentiality/anonymity

Overall impact:

- Sufficient detail - completeness (all the essential information)

- Clear exactly what happened and when, where, who, how, why

- Weight (accuracy; truthfulness; consistency; credibility; reliability) as evidence/truth/fact

- Any further information if needed

  • Signpost:

Source information/evidence – Who, what, where, when, how, why

Refer to evidence, documents, papers, books, notes, further sources of evidence/information if needed, etc

Specify exactly where these are held or can be located/found Eg Appendix ?

  • Fulfills objective/s (remit; Term/s of Reference)

COVER PAGE

  • Organization logo + address
  • “Private and Confidential” and “No unauthorized access or reproduction”
  • “Investigation Report”
  • Names – Investigating Officer; Supporting Officer
  • Draft/Version#

INSIDE PAGE

  • Title
  • Appointing officer – requested by/for
  • Investigating officer/author
  • Supporting officer
  • Dates appointed, commenced, concluded and released
  • Copies circulated to
  • Reader/s guide
  • Statement of Truth
  • Statement of impartiality/objectivity
  • Sign off – Name, signature, job title, role, contact details, date

CONTENTS/INDEX

  • List sections of report
  • List attachments

EXECUTIVE SUMMARY/SYNOPSIS

  • Brief overview of all sections

INTRODUCTION

  • Reader forms opinion about rest of report based upon the clarity and quality of the introduction
  • When, how and who appointed
  • What, why, where, when, who
  • Purpose of report – objective/s; remit/terms of reference

INVESTIGATION BACKGROUND AND CHRONOLOGY

  • Keep in note form initially to stop becoming too focused on this section
  • Often better to finish this section last
  • Make the context clear
  • Chronologically describe:

Method/process used to investigate, research, gather and record information

RCA:

- Gather information

(Paradigms, People, Systems, Resources/Equipment, Environment, Site, documentation/records)

- Map information

(Timelines; Tabular timelines; Time/person grids; Cause and Effect diagrams; Narrative chronology)

- Identify problems

- Analyze problems

- Develop solutions

SOURCES OF INFORMATION AND EVIDENCE

  • Attach as appendices or signpost where locatable
  • Participants/witnesses

Use initials (full name in indexed list)

Anonymize/remove for RCA/safety investigations

  • For EACH one, attach as appendix:
  • People
  • Environment
  • Physical
  • Audio-visual
  • Documentation/records
  • Circumstantial (applicable/relevant at the time):

CRITICAL INCIDENT/S – SEQUENCE OF EVENTS

  • Incident/s and event/s
  • ABC
  • RCA findings

FINDINGS

  • Reasons and underlying causes/failures – systemic; individual
  • Make reasonable assumptions and conclusions based on fact and burden of proof (who) and standard of proof (level – balance of probability)

CONCLUSIONS

  • Lessons to be learned

Organizational/systemic

Team

Individual

RECOMMENDATIONS – PRIORITIZED ACTION PLAN/SOLUTIONS

  • Link directly with what said in conclusion
  • Do not introduce any new ideas/issues
  • SMARTER actions (priorities, named leads and time scales) for:

Organizational

Team

Individual

SIGN OFF

  • Name, signature, date
  • Job title and role, contact details

APPENDICES

  • Notes/minutes
  • Statements, evidence and other information
  • Documents and systems
  • Supporting tools
  • Graphics

GLOSSARY

CONTACT DIRECTORY

REFERENCES/BIBLIOGRAPHY

Check “DRAFT” reportafter and appropriately change/amend

  • Hypercritical and ruthless
  • Review, scrutinize AND challenge what you have written afterwards

After a break/time out – preferably overnight/few days

After typed

After changes/returned

After final break/time out – preferably overnight

  • With:

Advisor, advocate, representative

Trusted friend/peer

  • For:

Legibility

Grammar and spelling

- Use a dictionary

- Wrong spelling can lead to confusion/incorrect interpretation (similar sounds, different meanings, etc)

Accuracy, truth, factualness, objectivity

Relevance and conciseness/brevity

Clarity

Consistency

Omissions, exaggeration, trivialization/minimization, errors/mistakes, discrepancies, ambiguities, inconsistencies, weaknesses, loopholes, counterattacks, hostility

Overall impact

Maintaining confidentiality/anonymity

Fulfilling objective/s (remit; Term/s of Reference)

  • Final check (when finished): Format, grammar/spelling, flow, readability

Sign, print name, date and time

  • Only sign if you are entirely satisfied and in agreement with EVERY aspect of content
  • DO NOT sign if:

Made under duress

You do not agree with content (errors, inaccurate, omissions, untrue, etc)

The information is beyond your knowledge

You are not going to have a copy of it

  • If you do not agree:

Make a formal note that you don’t agree, why, and sign

Get a reliable witness (Eg union, legal advocate) to countersign

Make or request a (signed AND dated) copy/copies

  • For: 1) Management; 2) Requested audience; 3) Any requests

4) You; 5) representative/accompaniment and/or 6) advocate/legal advisor

  • To be provided at the time of making/handing over the statement
  • Should voluntarily provide, but if don’t – ASK
  • File and store confidentially and securely
  • Retain for future reference/interview/cross-examination

Request written confirmation of receipt/handing over

  • Who (name, role, contact details)
  • When, where and how

ORGANIZATIONAL ISSUES

Legal and regulatory requirements/obligations

Paradigms

  • Culture
  • Values/principles

Systems

(Corporate/Clinical) Governance

Robust and effective ‘protective’ systems

  • Raising concerns, complaints, whistle-blowing/PIDA
  • Writing (formal) statements/reports
  • Serious/untoward incident review and investigations
  • Bullying, harassment, victimization, intimidation
  • Discrimination
  • Zero tolerance
  • Grievances, etc

Staff training and practice for writing reports

Staff support during, throughout, AND after process

  • Access to legal advice
  • Access to practical advice/help
  • Access to union advice/help
  • Resource provision (including uninterrupted time)
  • Debriefing

Reports for work-related events should be completed in works’ time

REFERENCES AND BIBLIOGRAPHY

Dimond, B (2005): Legal Aspects of Nursing. 4th Ed

Pearson/Longman

Heller, R and Hindle, T (1998): Essential Manager’s Guide

Dorling Kindesley

Impact Social Care Training (2008): Report format

RCN (2006): Writing reports for legal purposes. A-Z advice sheet

(accessed 26.05.2006)

The plain English guide to writing:

The plain English guide to writing reports:

(accessed 12.01.2006)

Thomas, J (2006): Survival guide for Ward Managers, Sisters and Charge Nurses

Churchill Livingston/Elselvier

Craig LongstaffCreated 27.08.2002 – Revised 05.10.2018Page 1 of 11