Death In Custody Clinical Reviews

Delphi employs a variety of investigative methods to identify potential causes of specific events. By reviewing and analysing patients’ clinical notes, risk assessments, and care plans, we can pinpoint areas of risk and recommend actions for improvement. We also use a PSRIF template to uncover the root causes of problems and propose solutions, complemented by a detailed timeline of events.

Our investigative approach integrates a systems approach, human factors, and ergonomics, using the Systems Engineering Initiative for Patient Safety (SEIPS) model and other tools recommended by NHS England. This ensures that we consider all elements of the work system, including people, tasks, tools and technologies, environment, and organisational conditions. By doing so, we aim to improve safety, clinical effectiveness, and patient experience.

Thanks to our impartiality, we provide unbiased, evidence-based reports grounded in the evidence presented. All investigations undergo peer review to ensure accuracy, consistency, and proportionality. We conduct interviews with involved staff using open and closed questions, maintaining a ‘no blame’ approach.

Adhering to the three pillars of quality within the NHS - safety, clinical effectiveness, and patient experience - Delphi boasts a team of experienced clinicians and senior operational staff. When necessary, we can engage expert subject matter associates. Our team includes Occupational Therapists, RMNs, RGNs, LD professionals, CQC Inspectors, and Operational Managers, all of whom have extensive senior-level experience in both the public and private sectors.

By incorporating a systems approach and focusing on human factors and ergonomics, Delphi's investigations are thorough and aligned with best practices for patient safety. This method allows us to identify systemic issues rather than attributing blame to individuals, fostering a culture of continuous improvement and learning.