Rebuilding Investigations Kit

Investigations of healthcare harm often overlook the valuable insights of patients and families. An initial research phase of this study reviewed literature, interviewed stakeholders (patients and families, staff who have been investigated and those who have conducted investigations, policy makers, patient safety researchers), and conducted a documentary analysis of policy statements for half the NHS Trusts in England and Wales. The findings from this research were complex, but communication of these findings was further complicated by issues of trust. Patients and families had experienced harm from initial healthcare, and then secondary harms from poor investigation processes. This activity was developed as a sense making activity that synthesises the evidence from the mixed methods research phase. Rather than telling people what the researchers found from the evidence, this activity enabled others to come to their own conclusions. It is based on an interactive narrative, that presents multiple perspectives of a serious incident. The narrative unfolds in three stages of [1] past (the initial incident or harm event), [2] present (the investigation) and [3] future (the aftermath or longer term impacts on the characters in the narrative). The narrative is told through a series of cards. The cards initial reveal the characters involved in the narrative, who are arranged on the narrative timeline, where each character has their own timeline of events. Subsequent cards reveal these events, and the person engaging in the activity arranges them in an appropriate order on an appropriate character timeline. The narrative is fragmented so the person engaging in this activity kit must piece together the story from the fragments to make sense of it. In phase 2, the person engaging in this activity is then cast into an active role in the narrative as the incident investigator. They make choices about who they are as an investigator and gain access to different kinds of evidence. This is repeated, the second time as a different investigator. In the concluding part of this narrative, the person engaging in the activity finds out what the longer term impacts of the incident and the investigation have been in different characters in the narrative.