Investigation
Stage 4: Conduct investigation

Unless there are exceptional circumstances, the investigation must:

• commence at the earliest opportunity and, in any case, within 4 weeks of the decision to investigate
• include a visit to the scene of the incident

In all cases:

• record whether a site was made
• record the reasons if the scene was not visited

If the investigation does not proceed due to inadequate resources or other developing priorities:

• record this provisional decision on a DRF
• refer the provisional decision to the senior line manager and request approval

go to step 2.4

As soon as practicable after beginning the investigation, identify and contact:

• the dutyholder to explain your role and the investigation objectives
• the injured person
• any employee/safety representatives
• record the significant contacts made

If a fatal, as soon as practicable after the investigation begins:

• contact the appropriate members of the bereaved family
• record the significant contacts made

• provide appropriate support to investigating staff

If there is risk of serious personal injury:

• take the necessary immediate enforcement action

Seek to achieve the objectives of the preliminary investigation by:

• gathering information
• analysing the information
• developing findings
• drawing conclusions

Where other agencies are involved:

• continue to liaise in accordance with step 3.3

Where a bereaved family is involved:

• keep them informed of progress in accordance with step 4.3

In all cases:

• record the significant contacts made

When the objectives of the preliminary investigation have been met, decide the scope and extent of any further investigation necessary to:

• identify the immediate and underlying causes
• identify the lessons learned
• collect any further evidence

When the investigation reaches the point where an enforcement decision should be made:

• apply the enforcement management model

Continue the investigation until:

• the objectives are met

unless:

• information comes to light that the incident is not within HSE's area of responsibility or which alters an earlier decision on HSWA s.3 policy
• it becomes apparent that the incident does not meet the selection criteria
• one or more of the decision-making factors are relevant: investigation is impracticable; no reasonably practical precautions are available for risk reduction; inadequate resources or other developing priorities prevent the investigation continuing

or, either of the following criteria for concluding the investigation apply:

• the related breach of health and safety law is unlikely to have been serious (i.e. where the outcome of applying the EMM, including applying the dutyholder and strategic factors, does not result in a notice or prosecution) and there are no more lessons to be learned
• disproportionate effort would be required to achieve the established objectives

Where the investigation is concluded because of inadequate resources or other developing priorities:

• refer to your line manager for approval

Bearing in mind its purpose, review the progress of the investigation with your line manager at regular intervals to decide:

• whether the incident is to be investigated any further, or
• if the investigation should now be concluded

Performance standard:

• review the investigation whenever significant information comes to light which affects the course of the investigation, otherwise
• the first review must be within 3 weeks of the decision to investigate

Where the decision is to continue the investigation:

• review the objectives for the preliminary investigation set in step 3.1
• revise them and/or establish new objectives if necessary, e.g. for the purpose of collecting sufficient evidence to inform a decision on enforcement action
• identify and agree reasonable lines of enquiry
• where it is being maintained, record the key decisions taken in the key decision log
• set a date for the next review no later than 2 months hence

Performance standard:

Record the outcome of the review, including:

• the reason(s) for continuing the investigation
• any agreed revised objectives and further agreed lines of enquiry
• the date of the next review

When the investigation is concluded:

• record the reason(s) for concluding the investigation
• where appropriate, complete and retain the key decision log
• report the findings and proposed action

Where the investigation is concluded because of inadequate resources or other developing priorities:

• record the line manager's approval

Advise all the interested parties of the outcome of the investigation, and the action required, and by whom, including:

• the dutyholder(s)
• other stakeholders, eg, trade associations
• any bereaved family
• any injured person
• any employee/safety representatives
• other parts of HSE
• other agencies

In particular :

• consider if any written advice should be provided to the dutyholder
• record significant contacts

If the incident was a fatal:

• inform the Coroner that the investigation has been concluded
• agree disclosure of information for the purposes of the inquest

If the follow-up is with the dutyholder:

• follow the relevant steps in the Inspection procedure

go to inspection procedure

If follow up is with other interested parties inside or outside HSE:

• take other appropriate action

On COIN:

• send a notification to the appropriate person for any follow up