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Formal, quasi-legal, inquiries into homicides, suicides and serious incidents, even when sensitively and carefully conducted, may be experienced as persecuting to staff, excessively blame-orientated and damaging to an already weakened service. Many reports simply identify the individuals responsible and their particular failures, without considering the broader organisational context. In the present paper we describe a structured and systematic method of investigating adverse incidents on an acute psychiatric ward which draws attention to the wider organisational context as well as to the actions or omissions of individuals. An analysis of a serious incident, albeit one from which no permanent harm resulted, is also presented. Detailed analysis provides information both about specific management problems and more general unsafe features of an organisation, such as deficiencies in training or supervision, and problems in written or verbal communication, both between staff and between staff and patients.

Original publication




Journal article


Journal of Mental Health

Publication Date





89 - 103