Investigation outcome and Root

Cause Analysis (RCA) template

Client incident management system (CIMS)

Contents
1. Incident reference number................................................................................................................................
2. Service Providers details..................................................................................................................................
3. Incident details..................................................................................................................................................
4. Allegation findings.............................................................................................................................................
5. Rationale for conducting the case review.........................................................................................................
6. Communication strategy...................................................................................................................................
7. Incident response plan......................................................................................................................................
8. Incident investigation report approval/Allegation outcome report......................................................................
Case review...............................................................................................................................................................
Review period.............................................................................................................................................................
Service details.............................................................................................................................................................
Case review manager details......................................................................................................................................
Defining the problem...................................................................................................................................................
Case review methodology...........................................................................................................................................
Interviews....................................................................................................................................................................
Documentary or other evidence reviewed...................................................................................................................
Assessment and key issues identified........................................................................................................................
Case review action plan.........................................................................................................................................
Case review report endorsement..........................................................................................................................

[The investigation outcome and case review template is to be used when the investigation manager, on the balance
of probabilities, is able to determine an outcome for an allegation of abuse or poor quality of care at the time of
investigation and that a case review is a more appropriate response. All documents must be stored in a secure
location to protect the privacy of the parties involved and to ensure the integrity of the investigation is maintained.
The investigation outcome and case review report template must be completed within 28 business days of the
divisional office endorsing the recommendation to conduct this follow up action. It must be approved by the service
provider chief executive officer/senior delegate and recorded on the service provider’s client incident register.
The text in orange throughout this template serves as a guide and should be deleted.]

1. Incident reference number

<Enter incident report ID (IRD) here>

2. Service Providers details

Organisation name <Enter organisation name here>

Investigation outcome and Root Cause Analysis (RCA) template

3. Incident details

1.

2.

3.

3.1. Details of clients involved in the incident

Client 1
[This section only required to be completed if IR does not contain sufficient details of the client/s.]

Client’s full name <Enter the client’s full name here>

Date of birth <Enter the client’s date of birth here> [DD/MM/YYY]

Primary incident type <Enter primary incident type, as identified in the incident report,
here>

Secondary incident type (applicable for <Enter secondary incident type, as identified in the incident report,
incident types of abuse only) here>

List allegations/unexplained injuries [Described in more specific detail the nature of the allegation/s. List
allegations/unexplained injuries for example allegation 1 – physical
abuse, allegation 2 – sexual abuse, when providing specific detail]

[Copy and paste the Client 1 table for each client impacted by the incident, as required, up to a maximum of 10.]

3.2. Details of subject(s) of allegation(s)

[This section only required to be completed if IR does not contain sufficient details of the subject(s) of
allegation(s)]

Subject of allegation1

full name of the subject of allegation <Enter the full name of the subject of allegation here>

Date of birth <Enter the date of birth of the subject of allegation here>
[DD/MM/YYY]

Sex <Enter the sex of the subject of allegation here>

Home address <Enter the current home address of the subject of allegation here>

Indigenous status <Enter the indigenous status of the subject of allegation’s, as

identified in the incident report, here>

Role in incident <Enter the role in incident of the subject of allegation here>
[Include the capacity the subject of allegation’s was acting in, for
example the position title if staff and type of carer for volunteers.]

Client unique ID <Enter client’s unique ID, if applicable, here>

Investigation outcome and Root Cause Analysis (RCA) template

 Client unique ID type (e.g. CRIS or <Enter client’s unique ID type, if applicable, here>
CRISSP number, HiiP ID, etc.)

[Copy and paste the subject of allegation table for each subject of allegation, as required, up to a maximum of 10.]

4. Allegation findings
[The outcomes are to be clearly and concisely stated. Each substantiated allegation is to have an outline of the
processes, the witnesses interviewed, and evidence examined which led to the outcome.]

• Allegation • Evidence Considered • Outcome

<Enter outcome for allegation 1 <Enter the relevance of the evidence considered, that
here> is, how the evidence, on the balance of probability,
substantiates the allegation here>.

[Add additional lines if required.]

5. Rationale for conducting the case review

[Why is a case review the most appropriate course of action?]

<Enter the rational for conducting the case review here>

6. Communication strategy
Used to notify clients, staff and others of the review while it is underway
[Note: Confidentiality procedures and protection of the client’s and any subject/s of allegation(s) identities must be
followed at all stages]

• Description • Timeline

<Enter the communication strategy here> <Enter timeline here>

[How will each of the key stakeholders involved in the [For each of the communication steps identified
review be kept up to date with the progress and any provide timeline details for when they will be
outcome of the review?] conducted, who will be responsible for communicating
with each person and when will it be completed.]

Investigation outcome and Root Cause Analysis (RCA) template

7. Incident response plan
[The Incident response plan outlines the follow up actions identified by the service provider to respond to the incident outcomes. If the allegations are not
substantiated, service provider practice improvements must still be identified with the service provider service improvement section of the Incident response plan
completed below.]

Outcome Response Theme Response Expected result Timeline Monitoring

<Enter outcome here> <Choose one theme* / <Enter response <Enter expected result / <Enter anticipated <Enter how action will
category of response planned for outcome, rational for planned timeline for planned be monitored by service
here> including actions and response here> response here> provider here>
support for clients
(client impacted /
subject of allegation /
witness) here>

[Note: one response theme is mandatory unless the outcome of the investigation is ‘not substantiated – no further action’.
*Response theme options (choose one per outcome): Client placement/mix, Client plan, Client access to support services, Staff capability, Staff or Carer
qualification/accreditation, Staff terminated/stood down, Staff rostering/support model, Operational policy/procedure, Property repair/upgrade/modifications
required, Human resources policy/procedures, Organisational governance, Notify relevant parties, Other]
[Copy and paste the Investigation response plan template as required.]

Investigation outcome and Root Cause Analysis (RCA) template

8. Incident investigation report approval/Allegation outcome report
Details of person who prepared the incident investigation report

Prepared by <Enter name of person who prepared incident investigation report (the
investigation manager)>
Position/title <Enter position or job title of person who prepared incident investigation report>
Conflict of interest I declare that I have not had any prior personal involvement in this matter, nor do I
declaration: have any personal bias or inclination, obligation or loyalty, that would in any way
affect my conducting this investigation; nor any comments or critical analysis that I
provide. As the investigation manager, I have verified that any other staff member
involved in conducting the investigation also does not have a conflict of interest
relating to this incident.
Signature <Enter signature of person who prepared incident investigation report. Electronic
signatures are acceptable.>
Date <Enter date of above signature> [DD/MM/YYY]

Details of the person who approved the prepared incident investigation report

Approved by <Enter name of person who approved the incident investigation report>
[Service provider’s Chief
executive officer or
delegated authority]

Position/title <Enter position or job title of person who endorsed incident investigation report >
Signature <Enter signature of person who approved the incident investigation report.
Electronic signatures are acceptable>
Date <Enter date of above signature> [DD/MM/YYY]

Investigation outcome and Root Cause Analysis (RCA) template

Case review
Case reviews provide a professional practice framework to generate insight as to why an incident happened and to
capture the key learnings from that incident. It is intended to support continuous improvement by reflecting on the
client incident, exploring what might have caused it and documenting the lessons and actions the service provider
will take to reduce the risk of the same type of incident occurring again in future. A case review in CIMS should
primarily be based on a desktop review of available documentation. A separate template is available for reference
and use as appropriate for when root cause analysis methodology is used to conduct an incident review.

Review period
Proposed review start date <Enter the proposed review start date here> [DD/MM/YYY]
Proposed completion date <Enter the proposed review completion date here> [DD/MM/YYY]
[Within 28 business days of the [A provisional due date will be provided by the department
department endorsing the divisional office upon endorsement of the recommendation to
undertake a case review in response to a major impact incident]
recommendation to conduct this follow up
action]

Service details
[The section only required to be completed if not the service provider identified in the IR.]

Address of service delivery <Enter address of service delivery here>

Area <Enter Department of Health and Human Services service area here
[As identified in the incident report] >

Program <Enter program here >

[As identified in the incident report]

Service type <Enter service type here >

[As identified in the incident report]

Case review manager details

[Refer to the Client incident management guide for the role, responsibilities and independence of the review
manager]

Surname / family name <Enter surname / family name here >

Given name <Enter given name here >
Position title <Enter position title here >
Telephone <Enter telephone here >
Email <Enter email here >

Defining the problem

[Include a clear concise description of the issue(s) that are in scope of the review]

Investigation outcome and Root Cause Analysis (RCA) template

 <Enter the details of the problem here>

Case review methodology

[Outline the key activities undertaken as part of the Case Review process, noting that the Case Review Manager
may be required to undertake document reviews and speak with clients and staff members present at the incident
and managerial staff. It is not mandatory for interviews to be conducted face to face, however it is likely there are
circumstances where it is desirable, for example when speaking with the victim.
[Examples include, but are not limited to, reviewing client file notes, medication chart records, organisation
occupational health and safety policies, other relevant reports about the service provider and speaking with
relevant clients and staff.]

Activity Rationale for activity Responsibility Timeline

1
2
3
4
[Add additional lines if necessary]

Interviews
Where deemed necessary interviews should be concise and targeted to the issues that are identified as in scope of
the case review and not as detailed as would be expected for a Root Cause Analysis Review.
Consideration should be given as to whether it would be appropriate to interview the client/s involved.

Name <Enter the name of person interviewed here >

[Including position title if a staff member]

Date, time and location <Enter date, time and location of interview here>
People present <Enter all people present at the interview and their role here >
Purpose of interview <Enter Reason for person interviewed here >
Key information collected in Interview: <Enter summary of information here >
[Include only relevant information. Full case
notes of interviews can be attached to the
case review report if required]

Assessment of information: <Enter assessment of information here>

[Is it relevant, credible and objective?]

[Copy and paste the interview details table for additional interviews, if required.]

Investigation outcome and Root Cause Analysis (RCA) template

Documentary or other evidence reviewed
[Unless other considerations have been given under allegation findings there is no need to reproduce.]

List of documentary or other Date and source of documentary What is the relevance of the
evidence reviewed or other evidence reviewed documentary or other evidence
reviewed?

[Examples include, but are not [This is the date when the [For example: does it support
limited to, reviewing client file documentary or other evidence was verbal accounts of the impact to the
notes, medication chart records, originally completed and where/who client? Does it demonstrate that
service provider occupational it was obtained from.] adequate actions were taken to
health and safety policies, other support the client both immediately
relevant reports about the service after and following the incident?
provider.] Were actions consistent with
organisational policies and
procedures?]

<Enter documentary or other <Enter the date and source of <Enter the relevance of
evidence reviewed here > documentary or other evidence documentary or other evidence
reviewed here > reviewed here >

[Add additional lines if necessary]

Assessment and key issues identified

Incident management assessment

Describe how the client/s involved were supported both during and after the incident and had their safety needs
met (examples include, but are not limited to, engagement of a support person or advocate for the client, contacting
police or seeking medical attention for the client, the use of communication aids)

<Enter the incident management assessment here>

If the client/s were interviewed, describe their account of how their needs were met during and following the
incident.

<Enter the details of the client account/s here>

Investigation outcome and Root Cause Analysis (RCA) template

Was the service provider’s response and actions consistent with both department and service provider policies and
procedures?

<Enter the assessment of whether the service provider’s response and actions were consistent with policy here>

Key Issues identified

[What information has been assessed as pertinent to inform the case review recommended action plan and why?
What does the information tell us about why the incident occurred? Is there a possibility of a similar incident
occurring again and why?] [If the client accounts differ from the service providers account, what needs to happen to
resolve this?]

<Enter the key issues identified here>

Key learnings
[What are the lessons that have emerged from this incident? What can be done differently in future to avoid or
reduce the same thing happening again?]

<Enter the key learnings identified here>

Investigation outcome and Root Cause Analysis (RCA) template

Case review action plan
[In the table below, outline any specific actions to be implemented in response to the identified contributing factors/causes of the incident/s, who is responsible for
these actions (that is, a specific individual, all staff who work with the client, a memo to be sent to all staff in the organisation, etc.) and when this is to be
implemented (ongoing or a specific date).]

Identified contributing Action/Recommendations Responsibility Timeline

factors/causes

[Add additional lines if necessary]

Investigation outcome and Root Cause Analysis (RCA) template

Case review report endorsement
Prepared by <Enter name of person who prepared the case review report (the review manager)
here>

Position/title <Enter position or job title of person who prepared the case review report here>

Conflict of interest As the review manager, I declare that I have not had any prior personal
declaration involvement in this matter, nor do I have any personal bias or inclination, obligation
or loyalty, that would in any way affect my conducting this review; nor any
comments or critical analysis that I provide. As the review manager, I have verified
that any other staff member involved in conducting the review also does not have
a conflict of interest relating to this incident.
Signature <Enter signature of person who prepared the case review report >

Date <Enter date of above signature> [DD/MM/YYY]

Approved by <Enter name of person who approved the case review report here>
[Service provider’s Chief
executive officer or
delegated authority]

Position/title <Enter position or job title of person who endorsed the case review report here>

Signature <Enter signature of person who approved the case review report here. Electronic
signatures are acceptable>

Date <Enter date of above signature here> [DD/MM/YYY]

Investigation outcome and Root Cause Analysis (RCA) template

 To receive this publication in an accessible format phone 1300 024 863, using the
National Relay Service 13 36 77 if required, or email the client incident management
system team <[email protected]>
Authorised and published by the Victorian Government, 1 Treasury Place, Melbourne.
© State of Victoria, Department of Health and Human Services January 2020.
Available at client incident management system <https://providers.dhhs.vic.gov.au/cims>

CIMS incident investigation outcome and RCA Template 12