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Incident Decision Tree

Reference number
Issue date01 February 2004

NOTE NHS England is currently working to update and reinstate the Incident Decision Tree and sincerely hopes it will be ready for relaunch in early 2015. This page will be updated with more details about the project as soon as they become available.


We thank you for your continued patience in relation to the Incident Decision Tree.


The Incident Decision Tree aims to help the NHS move away from attributing blame and instead find the cause when things go wrong. The goal is to promote fair and consistent staff treatment within and between healthcare organisations.

Research carried out in the NHS has shown that systems failures are often the root cause of safety incidents. However, the most common response to a serious patient safety incident is to suspend and then discipline the staff involved. This can be unfair to employees and divert management from identifying contributory systems failures. Suspending key employees can also diminish the quality of patient care provided.

The Incident Decision Tree can help managers and senior clinicians:

  • decide whether it is necessary to suspend staff from duty following a patient safety incident;
  • explore alternatives to suspension, such as temporary relocation or modification of  duties; and
  • consider other possible measures to be taken as the investigation progresses.


The Incident Decision Tree complements the Root Cause Analysis toolkit.