INFORMATION SHEET 11Investigation Report template

File No:

Name and position of the staff member/clinician:
Employee number: Registration number:
Name and position of investigator:
Date investigation commenced:

Trim No:

Background

This section should state details of the potential misconduct, unsatisfactory performanceand how and when it came to the attention of the NSW Health organisation(including who provided the information, when and how) and why a decision was made to conduct an investigation (include copy of initial review).

Summary of allegations/suspected misconduct/complaint or concern

Include an objective numbered summary of each allegation/ suspected misconduct /performance issue as provided for response to the staff member/clinician. Each allegation, complaint orconcern should state clearly when, who, where and what has allegedly happened as well as any potential or alleged consequences (if known). It should also state, where possible, what policy, procedure, guidelines, standard, law etc has alleged been breached or not met.

Scope of the investigation

State the purpose and scope of the investigation (including what the investigation was expected to deliver eg findings, analysis etc).

Attach Terms of Reference in appendix.

Relevant legislation, awards and policies

List relevant legislation, industrial awards and/or policies used to reach a finding and prepare the report, and detail relevant considerations for the investigation.

Conduct of the investigation

Summarise the investigation process and methodology followed:

  1. Details of evidence obtained and how it was obtained: eg
  2. List of people interviewed and interview records or summaries (attach in appendix)
  3. List of written statements received (attach in appendix)
  4. Clinical practice or indicator data, variation reports, clinical reviews
  5. Other evidence to support or refute claims (eg computer records, rosters, clinicalrecords, minutes of meetings, letters etc –attach all in appendices)
  6. Worksheet outlining chronology of investigation process (showing when letters were sent, interviews were held etc). (Attachin appendix.)

Information gathered

Summarise all the evidenceprovided by the complainant (the complainant is whoever raised or identified the allegation, concern or complaint), the alleged victim (if there was one), affected patients and each witness. State clearly why each person was interviewed and what evidence they provided, quoting verbatim any significant points. If certain witnesses or alleged victims were not interviewed, the reason for this should be clearly stated.

Summarise information from all other evidence gathered.

Summarise the response from the staff member/ clinician, subject of the investigation,to each allegation/concern.

Analysis of the information

In analysing the evidence, consider its reliability, relevance, consistency and corroboration and any other factors that affect it (for example, conflicts of interest, bias, time since alleged incident may weaken the strength of evidence). Indicate what weighting was given to various pieces of information, stating why certain evidence was preferred and why other evidence was not given much weight or discounted.

For example, was one witness more credible than another in their account of what happened and if so how?

Note two potential ways of recording analysis.

Option 1 - List each allegation/concern individually

Allegation 1 – provide detail

  • Evidence to support
  • Evidence to refute
  • Analysis of evidence

Option 2 – Consolidatedassessment of all allegations

  • Areas of agreement and relevant evidence
  • Areas in dispute and relevant evidence
  • Overallanalysis of all allegations and facts, indicating what weighting was given to various pieces of evidence.

Conclusions based on analysis

Summarise investigatory findings based on analysis. Consider and answer every allegation made/concern identified, including how a finding was reached. The findings should clearly flow form the analysis.

State whether the content of each allegation/concern was substantiated. If only part of an allegation/concern or complaint was substantiated, the report should clearly state which aspects were substantiated.

For any substantiated conduct, state whether it constituted misconduct, unsatisfactory performance etc

Possible misconduct findings include:

  • misconduct is substantiated
  • misconduct is not substantiated (the conduct that was substantiated did not constitute misconduct, there is no evidence that the conduct occurred as alleged or there is evidence that it did not occur)
  • misconduct is not substantiated due to insufficient or inconclusive information (ie there is not the required level of evidence to be able to make a findingthat the conduct occurred as alleged).

Specific requirements apply to findings that can be made for child-related allegations that are notifiable to the Ombudsman. Refer to the current NSW Health policy on Child related allegations, charges and convictions against employees.

For performance issues

If unsatisfactory performance is found – state what the performance was that was unsatisfactory, how it was unsatisfactory (ie what standard is it being measured against?) and what is its impact ( ie how serious is it)

When making findings, also consider any mitigating or aggravating circumstances and the role of those circumstances. For example, is there evidence of impairment as a contributory factor to the staff member/ clinician’s performance or conduct.

Note: All investigation findings must be based on the balance of probability, ie it must be more probable that the conduct has occurred than that it has not occurred.

Steps in making findings:

  1. Which aspects of the conduct/performance/behaviour are substantiated?
  2. What is the nature of the substantiated conduct/performance/behaviour – misconduct, unsatisfactory performance, or something else?
  3. Any mitigating or aggravating circumstances that need to be taken into account in any findings such as impairment
  4. Does the substantiated conduct/performance /behaviour require findings in respect of external agencies – for example, Ombudsman - reportable conduct, Children’s Guardian -relevant misconduct findings, AHPRA – notifiable conduct, relevant professional Council – unsatisfactory professional conduct or professional misconduct etc (State any associated reporting requirements)

Appendicesindex

List all appendices attached.

Name of investigator:______

Signature of investigator: ______

Date:______

Findings supported/not supported–provide detailed reasons:

Further action (eg adverse findings supported -> seek a response from the staff member/clinician; findings not supported -> further inquiries required etc):

Name of decision-maker:______

Title:______

Signature: ______

Date:______

Last updated August2017supportingMANAGING MISCONDUCT & MANAGING COMPLAINTS AND CONCERNS ABOUT CLINICIANS 1/3