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Root Cause Analysis Investigations — A short guide to effective report writing

A root cause analysis investigation is an investigation undertaken to establish the originating causes which have led to a death or an avoidable…

What is a root cause analysis investigation?

A root cause analysis investigation (“RCA”) is an investigation undertaken by an organisation/NHS trust to establish the originating (or ‘root’) causes which are likely to have led to a death or an avoidable event. The focus of the investigation is on establishing causes and contributory factors and what lessons can be learned from them as a result. Considerations may include:- i). establishing what happened ii). how to address the family concerns; iii). how to reassure those with an interest in the investigation (including the coroner) that the investigation has been thorough and robust iv). ensuring that any points of concern/action points have been addressed.

Below is a set of factors to consider as a guide to assist when undertaking an RCA report on behalf of your organisation:

1. Establish the facts

This may seem like an obvious factor, however it may be easy to get drawn into speculation, particularly if many staff are involved (who may offer differing views on the care). In order for the RCA to be factually accurate and for the findings of the root causes to be robustly supported, it is important that any assertions made within the report (positive or negative) are supported with reference to the evidence (e.g. medical records, statements etc). It will usually be helpful to include a timeline or chronology to assist the audience reading the report to understand the key facts (e.g. the trust witnesses, who may be called to give evidence at the inquest; and the coroner, who will decide upon the scope of the inquest).

2. Stick to the framework

Most RCA’s will have a section setting out a ‘terms of reference’ which focuses the investigation on the key areas that will be reviewed. The terms of reference should be sufficiently broad to investigate the main areas of concern; however care should also be taken not to open the investigation up too widely. Otherwise the report may become unfocused and there is often a danger that the issues may become ‘blurred’. A key point to assist with this is to check and re-check that the sections being drafted match at least one of the terms of reference for each section of the report. 

3. Avoid being overly 'self-critical'

There can be a tendency to fall into the trap of ‘hindsight bias’, (i.e. criticism with the benefit of hindsight that the actions that should have been taken which now seem obvious). There is a risk that this can lead to a misinterpretation of findings. The duty of candour is now well embedded within healthcare organisations (Health & Social Care (Regulated Activities) Regulations 2014) and there may be a feeling that the report should have a ‘critical’ edge. However, it is important to support any criticisms (particularly if they relate to individual staff members) with reference to key evidence and facts. It is also important to interview any staff members who may be criticised within the report, and that the report is shared with them in draft form for their comments (this will assist with avoiding inaccuracy in the findings). There may be at times a tendency to be overly ‘self-critical’ of the organisation/trust, however it is important to remember that the report is also a learning exercise and should be undertaken as independently, neutral and fact specific as possible. The purpose of an inquest is not to establish ‘blame’ and therefore the tone of the report should reflect this also.

4. Where possible, involve the family

At the start of an RCA investigation, it is advisable to write to the family and invite them to submit any views they may wish to express or any aspects of the care they would wish the investigation to explore. This will assist with building and maintaining good lines of communication throughout the process and may assist with managing the family’s expectations of what the investigation (and the inquest) can achieve. It may also form a part of fulfilling the trust’s duty of candour obligations and may ease any tensions that exist between family and staff members in advance of attending an inquest. Sharing the report with the family at the same time as the coroner or a few weeks in advance of a pre-inquest review hearing/the inquest itself is advisable, in order to minimise stress for trust witnesses and families. This is likely to also mean that there are fewer ‘surprises’ for the family when they attend the inquest.

5. Create and implement an 'action plan'

It is advisable to create an action plan to address any of the root causes which have arisen as a result of failings/errors within the organisation, particularly if they have resulted in an avoidable death, or would have ensured the patient received a better experience. You should try to ensure that the actions are robust and fully address the concerns raised by the ‘root causes’ section of the report. It is important that the actions have been implemented (particularly when it comes to attending an inquest) by the dates which were set for implementation. Otherwise the report may appear less effective and suggest that the learning has not been embedded. There should therefore be some evidence to demonstrate that the RCA’s action plan has been implemented prior to an inquest. Otherwise the coroner may feel duty bound to issue a Prevention of Future Deaths report (‘PFD’) to the trust under Regulation 28 of the Coroner’s (Investigations) Regulations 2013. If this occurs, it will require close consideration and a formal response will be required from the chief executive of the organisation/trust who receives the PFD within 56 days.


The audience of the RCA report will assess the report by its quality. Care should be taken to ensure the report is clear, concise and logical. Knowing who the report is being shared with will help the author(s) to decide upon the style of the report. (An acceptable pseudonym for the patient name is best agreed with the family themselves, for example). Prior to the final release of the report, it may be advisable to seek legal advice on the content and/or to proof read and fact check the report. The report will be ideally of use to all parties including the trust, the family and the coroner.

If you have any questions or queries about this article or about drafting an RCA report, please do not hesitate to contact David Reddington, lawyer, on 020 7822 1925 or by email:

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