I have currently designed an investigation method and a training model which is under consideration with the trust a step/method approach, as soon as it has been agreed I will happily post. It has moved away from RCA per se, but still retaining it as an analytical tool within alongside other approaches. The method looks at investigative foundations, investigative methodology, witness interviewing, support tools and methods of analysis, hierarchy of learning and recomendations, supporting families, staff and establishing what is need for systems change. I am trying to make it a more flexible investigative approach that can respond to incident at hand.
As aluded to above I agree from my time here there are repeated themes/events/learning and beyond this method I want to look at systems contsraints that enforce the necessary behaviour changes e.g. People, Systems and Tasks
Investigations & Learning Specialist
Royal Wolverhampton Trust