Appendix 5: Fact-finding investigation – model structure

Executive summary

The main points, findings and conclusion summarised for quick reading.

Purpose of the report

Clearly identify the remit. Agree this with the person commissioning the report and get it in writing. Is it just to report findings (what happened) or to make recommendations (what needs to be done to address the findings)?

The process of producing the report

Details about who has written it and the process e.g., who was interviewed and when, supporting information such as the write-ups of the interviews, other agencies who contributed, examination of case records and files, telephone calls etc.

Two or four key questions for the investigation to address

It is useful to identify 2-4 key questions for the investigation to address. Write them down. This helps to maintain the focus and ensures that at the conclusion, the investigation achieves what it set out to do.

Background and contextual information

Brief history of the circumstances and background leading up to the incident.

Detailed description of the alleged harmful event

Write this up in detail. Sources will include interviews with the reported victim, staff, witnesses and significant others. What happened before, during and after the event?

Assessment of the impact of the alleged harmful event on the reported victim

Identify the emotional, psychological, social and physical impact on the reported victim, e.g., withdrawal, injuries, changes in mood and behaviour that are out of character, effect on mental health and relationships, impact of loss of property or money etc.

Chronology of events, actions and decisions

This is a key tool.

Insert a two-column table that briefly summarises (1) the main events and what happened, who was involved and where and (2) when, with day, date and time.

This enables an at-a-glance summary of events and can be used like a map to find your way around the report. (Otherwise, it is too easy to lose track of what happened, who was involved and when).

The facts that were established

State what facts were established using your 2–4 key questions.

What can you say happened with (1) certainty (2) is likely to have happened on the 'balance of probabilities' or for which 'there are reasonable grounds for belief' or (3) did not happen because there is no evidence to support it?

Separately identify corroborated, uncorroborated and disputed statements or facts.

Possible explanations for key questions

Suggest possible explanations based on the above section.

Additional findings

Opportunity to make other observations that may be strictly out with the original remit but have emerged and are relevant

Action plan

Who will do what by when, resources needed and arrangements for review to ensure that change will be lasting.