Case Studies

Here are a selected sample of consulting work undertaken recently.

Investigation in Clinical Practice

Context - NHS Trust required independent review of internal SI review after post-operative patient death. [2018]

Brief- To review internal SI report and determine it’s adequacy in addressing care delivery problems identified.

Delivery- Independent single reviewer

* Agreed TOR with Executive MD

* Interviewed relevant parties including bereaved spouse and medical practitioner

* Read relevant clinical documentation including surgical records and hand over notes

* Deployed national level guidance on SI investigations to benchmark internal review.

* Submitted draft report

* Made required amendments and submitted final report

Outcome - Trust was able to gain assurance that their internal review had been robust and benchmarked favourably against national guidance

Key Learning- NHS Trusts need to better understand the system level factors that militate against patient safety and to have pro-active mitigation strategies to address them.


  • Dare to Care - Secure Base Leadership
  • Provider Strategy in The Emerging NHS Landscape


  • Sessional Ceremonies Team. West Sussex County Council - May 2013

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