Adverse incident final reports

On completion of an investigation of an adverse incident, the investigating team are required to prepare two reports:

• Report 1 public report (DOC 62KB) contains a description of an adverse incident, based on facts that, in the opinion of the investigating team, are known independently of its investigation and contain the recommendations of the investigating team as to the need for changes and/or improvements in relation to a procedure or practice associated with the incident.
• Report 2 (DOC 63 KB) contains a description of the adverse incident; a causation statement; the recommendations of the Root Cause Analysis (RCA) team; any other material considered relevant by the RCA team.

When the investigation has been conducted under the Act, the hard copy of both Report 1 public report and Report 2 should be endorsed by the investigation team. In addition Report 1 and those parts of Report 2 that a designated authority may have access to, should also be endorsed by the Chief Executive Officer of the health service entity or General Manager.

When the investigation has not been conducted under the Act, the hard copy of Report 2 should be endorsed by both the investigation team and the Chief Executive Officer of the health service entity or General Manager.