Formal Investigative Report – Death resulting from haemorrhage due to incised wound

Formal Investigative Report – Death resulting from haemorrhage due to incised wound
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Clinical Governance is the term used to describe a systematic approach to maintaining and improving
the quality of patient care within a health system. It is about the ability to produce effective change so that high quality care is achieved. It requires clinicians and administrators to take joint responsibility
for making sure this occurs.

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All critical incidents result from a series of underlying/predisposing factors resulting usually from human error, and deficiencies in systems and processes or procedures. When a series of factors line up in a certain way, an adverse event results. If the sequence of events is correctly analysed, the investigator can identify its origin and key points in the sequence, this allows the investigator to design mitigation strategies that can effectively stop that same sequence from recurring.

The task in this assignment is to:
Write a ‘Formal Investigative Report’ about the death resulting from haemorrhage due to incised wound as reported by the South Australian Coroner.

Please use the below as a guide of what you need to include in this report, the marking criteria will also help guide you.

Introduction/Background to the Incident: A short introduction including what the report is about followed by a brief background to the critical incident.

Data: Critically examine the case to identify and explore all the predisposing factors that lead to the outcome, these factors are the ‘root causes’. This information needs to be supported by a flow chart with annotations to present the complex details of the incident in an easy to view format.

Analysis: Analysis of the information presented in the ‘data’ section can be referred to as a ‘root cause analysis’ (RCA). The predisposing factors are explored in regards to why they existed and how they
lead to the incident. Any relationships between the factors is also explained. Use a ‘patient safety model’ diagram to demonstrate the factors that were the root causes that lead to the incident and to
identify factors that if mitigated would have prevented the incident from occurring.

NB: Root causes always form one or more chains of events. If a RCA is conducted correctly it will lead you back to the origin of this chain of events. If you can eliminate one or more of the root causes or break the chain of events you can prevent the same type of adverse event from recurring.
A patient safety model is a conceptual construct that guides the investigator in the process of analysis.

Discussion: In this section of the report current evidence-based peer reviewed literature is explored in relation to the incident and the root causes of the incident to develop a deeper understanding of the
why the incident occurred, what should have happened and how it could be prevented in the future.The National Practice Standards for the Mental Health Workforce 2013 should be discussed in relation to professional best practice with two (2) relevant practice standards being explored further. The literature discussed needs to be of a high quality and be current.

Recommendations: Evidence-based recommendations are made, which if implemented correctly would prevent the same incident from occurring again. Literature which supports the
recommendations needs to be presented, otherwise the report will have little credibility. Any recommendations must address the identified pre-disposing factors, in particular the ‘root causes’ and explain how the recommendations will mitigate these factors using a clear and logical approach.


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