Misconduct in Public Office? Beware! When a coroner gets their hands on a revised Serious Incident report…

Have you been ‘fiddling’ with your SI investigator’s reports?

With the best of intentions - health and care managers often seek to ‘improve’ the conclusions and recommendations made in reports. But - watch out, it is all too easy to turn something done with the best of intentions into disaster.

Far removed from the refined air of the courtroom, the business of producing SI reports is not always as straightforward as it should be. The investigation team pulls the evidence together, reaches conclusions and makes recommendations to improve practice within the organisation. In theory, that should be that. In reality, we all know from time to time an SI report hits the desk of a member of the senior team that does not seem to quite knock the issues on the head. On these occasions, the temptation to tweak, refine and, ultimately, revise the report’s conclusions/recommendations can be too strong to resist.

These documents will usually never see the light of a courtroom. However, on those occasions where they do, trouble awaits for both the organisation and the individual members of staff involved. Members of the investigating team are likely to be put in the unenviable position of ‘defending’ a report which is no longer truly their own. Inevitably, a scramble to avoid ‘egg-on-face’ ensues. An unsightly and public rift between the investigating team and senior staff becomes apparent, creating a perception that the findings of the SI report were “doctored”.

Recently, our inquest team witnessed a provider (not our client) falling afoul of such a situation first-hand. The provider was required to disclose the original version of the SI report. The coroner took the view that the evidence had been distorted. A referral to the Director of Public Prosecutions was made. Prosecution for misconduct in a public office was on the cards.

A bad outcome all-round. Talk about stress and reputational damage…

The solution is to make sure your investigators are properly ‘tooled-up’; understand and practice the best evidence gathering procedures and use the best analytical and drafting techniques. Properly train your investigations team so they are equipped with the skills to get it right first time, no amendments required.

We run a one day training session for senior staff charged with conducting investigations - to find out more, read our 2019 incident investigations flyer and get in touch with Stuart Knowles.

If circumstances dictate that amending an SI report is completely unavoidable, make sure the changes are both seen and agreed by the investigator/author. That individual needs to feel able to take ownership of the report’s contents should they be required to give evidence in court. Where an amended SI report comes to light and it is apparent this has not been done, transparency is the best policy: full and frank disclosure to the coroner in advance of the inquest will be the most effective way to avoid a public and messy fallout.

On a related subject, you can read Stuart Knowles' earlier post on preparing witnesses for appearance at inquest and what to do when you suspect an individual is playing it ‘fast and loose’ with the facts.

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Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.


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