Was the investigation conducted independently of the treating team?

Were family members given the opportunity to contribute to the investigation?

Is it clear from the serious incident report whether the investigation acquired access to full case records detailing the patient’s clinical history? If there are records missing is this clearly stated and are caveats made on the reliability of the findings and appropriateness of the recommendations?

Are the contributory factors leading to the incident presented (rather than a single root cause)?

Is there sufficient information to enable a thorough understanding of the circumstances of the death/incident, as well as the activity of the services involved?

Is the serious incident report coherent? Is there a clear and logical pathway from the ToR to the contributory factors to the recommendations; and is it clear how the recommendations could be used in prevention?

Is the serious incident report accessible to a lay reader? Is the report not too lengthy and written in plain English with all specialist vocabulary explained?

Does the serious incident report have an associated action plan with a timescale for review?

Does the serious incident report provide details of what needs to change in the service(s) and is there evidence of how learning will occur internally?