Investigations & Reviews

'Identifying learning, targeting improvement'


There are many different types of investigations and reviews, and an equally large variety of tools designed to maximise learning in each case. Iodem’s teams of highly skilled investigators have significant experience in this area, and our processes represent best practice.

We provide our clients with the expertise, skills, resources and independence necessary to conduct a pro-active safety and learning investigation.

Iodem can either manage or conduct an investigation, giving our clients the ability to free up management time which would otherwise be absorbed by handling the time intensive, day to day issues which are part of the investigation process.

We have a particular expertise in identifying the behavioural aspects of patient safety.

'One size does not fit all'

Iodem can provide advice on the type of investigation which should be carried out, in order to maximise the use of resources, and to deliver sought after improvement.

Our integrated tool kit enables us to undertake even the most complex investigations sensitively, efficiently, expeditiously and cost effectively.

At Iodem, we recognise that a comprehensive formal investigation may not be the best method of identifying the key issues, the contributory factors and the underlying system issues which could contribute to a safety incident.

Alternative approaches involving less complex processes may be a more efficient method of achieving change, and building a culture of safety.

At the core of every Iodem investigation is listening, discussion and observation. Our experience demonstrates that proper use of these tools maximises learning and generates change and improvement.

What Iodem Investigates:

The topics covered by our investigations into patient safety incidents commonly include:

  • Patient safety incidents
  • Individual, team and service performance issues
  • Complaints
  • Mental Health and domestic homicide investigations
  • Governance and systemic issues
  • Allegations of professional misconduct
  • Equipment failure or misuse
'Investigations that make a difference'

InvestigationsWe pride ourselves upon the quality of our investigations, which demonstrate a secure and transparent audit trail.

Iodem investigations are:

  • Proportionate and focussed on the opportunities for learning and prevention, by identifying system strengths as well as weaknesses
  • Targeted to identify and clarify the issues, we then work collaboratively to offer practical and effective solutions
  • Tailored to preserve relationships and ensure individuals are treated fairly and equitably

All of our reports are subjected to in house peer and legal review, in order that our findings can sustain clinical, legal and public scrutiny.


'Recommendations that support and drive sustainable change'

Sustainable change is not achieved by reminding staff to follow a lengthy policy, or to be vigilant.

Iodem recommendations are focussed on identifying practical solutions which improve the culture of safety in an organisation. They are typically structured around:

  • The re-design of tasks and processes to recognise the impact of human factors
  • Standardising processes and/or equipment, if appropriate
  • Reducing reliance on the policies and protocols to disseminate information. Iodem actively encourages the adaptation of policies and processes into bite-sized, user friendly formats
  • Consideration of working environments and the impact which that can have e.g. reducing the impact of repeated interruptions when delivering an episode of care

'People at the sharp end'

We never lose sight of the individuals at the ‘sharp’ end of a safety incident.

At the outset of every investigation, we set out clearly how we will engage and support individuals involved in an investigation. Whether they are the patient, the service user, a carer, a relative or a member of staff, they will be treated with fairness and respect throughout the investigation process.


'Safety is about building on the things that go well and learning from the things that go wrong'

Our toolkit includes provision for on-going practical support, advice and co-ordination during the implementation of our proposed evidenced based solutions.