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We carry out investigations to prevent the same or similar incidentÌýfrom happening again. This page provides guidance on how to communicate the recommendations from incident investigations.

On this page

• What are lessons learnt?
• How to communicate the investigation findings
• Who to communicateÌýthe investigation findings to
• Record keeping

What are lessons learnt?

The investigation will have addressed the following questions:

• What wasÌýthe immediate causeÌý– what went wrongÌý
• What was the underlying cause – why it went wrong
• Were there any aggravating factors –Ìýwhat made the likelihood that it would happen greater or made the consequences of the incident worse than they may have been in a different situationÌý
• Were there any mitigating factors –Ìýwhat made the likelihood that it would happen less or made the consequences of the incident less severe than they could have been

The investigation will have also considered the control measures:

• Were they sufficient?
• Can they be improved?
• Were they necessary?
• Are new controlÌýmeasures needed and if so what are they?

The summary reportÌýthat shares these conclusions and recommendations is called the .

How to communicate the investigation findings

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The content of the Lessons Learnt reportÌýwill depend on the incident and every report will be different but some general guidance is below.

• Keep it simple – this is not an investigation, consider what information you would need to know to ensure that the same incident did not happen again rather than all the information needed to understand why the incident happened
• Best practice needs to be communicated – investigations look at mitigating factors, human error will happen so it is important to tell people what worked to lower the consequences as well as telling them what went wrong
• Knowing what not to do can be as important as what to do
• Be clear and specific – everyone knows to review the risk assessment and the associated SOPs after an incident, however the report should cover what needs to be looked at and whetherÌýchanges shouldÌýbe made or why a particularÌýsection of the risk assessment or SOP needs review

Who to communicate the investigation findings to

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The lead investigator willÌýrecommend who to share the Lessons Learnt report with. This should be agreed with the Head of Department as the Chair of the Departmental Safety Committee and specialists fromÌýSafety Services or the Fire Safety teamÌýwhen relevant. The Departmental Safety Officer may also be consulted.

¹û¶³Ó°Ôº recommends the following groups are considered.

• The Injured/Involved Person (IP) – to ensure a positive and inclusive safety culture the report should be shared with the person who made the initial incident report and any people involved who were not part of the investigation
• The Departmental Safety Committee
• The Appointed Person group –ÌýwhenÌýan incident involves the followingÌýhazards, the reportÌýmust be shared with the relevant groups as listed within the departmental Responsible Persons Register in riskNET such as
  • CL3 lab managers
  • Fire marshals
  • First aiders
  • GM safety officers
  • Radiation protection officers
  • Laser safety officers

The lead investigator will also consider recommendingÌýwhether the report should be shared with the following groups.

• The rest of the research group
• The department
• Other faculties and departments at ¹û¶³Ó°Ôº carrying out the same activity
• ¹û¶³Ó°Ôº wider community
• The specific Health and Safety Sub-committee
• Communication and Marketing
• The further education and university community

Record keeping

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The Lessons Learnt report should be attached to the investigation report along with a record of who has received the report.