{"id":"https://openalex.org/W4403255461","doi":"https://doi.org/10.1186/s12913-024-11626-4","title":"Involvement in serious incident investigations: a qualitative documentary analysis of NHS trust policies in England","display_name":"Involvement in serious incident investigations: a qualitative documentary analysis of NHS trust policies in England","publication_year":2024,"publication_date":"2024-10-09","ids":{"openalex":"https://openalex.org/W4403255461","doi":"https://doi.org/10.1186/s12913-024-11626-4","pmid":"https://pubmed.ncbi.nlm.nih.gov/39385114","pmcid":"https://www.ncbi.nlm.nih.gov/pmc/articles/11463144"},"language":"en","primary_location":{"id":"doi:10.1186/s12913-024-11626-4","doi":"https://doi.org/10.1186/s12913-024-11626-4","is_oa":true,"landing_page_url":"https://doi.org/10.1186/s12913-024-11626-4","pdf_url":"https://bmchealthservres.biomedcentral.com/counter/pdf/10.1186/s12913-024-11626-4","source":{"id":"https://openalex.org/S12898181","display_name":"BMC Health Services Research","issn_l":"1472-6963","issn":["1472-6963"],"is_oa":true,"is_in_doaj":true,"is_core":true,"listed_in":["anvur-class-a","anvur-scientific","cwts-core","doaj","dongbi-b","doyens","fnege-4","jufo-2","ki-jl-1","medline","norway-1","oarl","poland-100","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320256","host_organization_name":"BioMed Central","host_organization_lineage":["https://openalex.org/P4310320256","https://openalex.org/P4310319965"],"host_organization_lineage_names":["BioMed Central","Springer Nature"],"type":"journal"},"license":"cc-by-nc-nd","license_id":"https://openalex.org/licenses/cc-by-nc-nd","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"BMC Health Services Research","raw_type":"journal-article"},"volume":null,"type":"article","is_traditional":true,"indexed_in":["crossref","doaj","pubmed"],"open_access":{"is_oa":true,"oa_status":"gold","oa_url":"https://bmchealthservres.biomedcentral.com/counter/pdf/10.1186/s12913-024-11626-4","any_repository_has_fulltext":true},"authorships":[{"author_position":"first","author":{"id":"https://openalex.org/A5086152049","display_name":"Siobhan McHugh","orcid":"https://orcid.org/0000-0002-5153-8092","observed_orcids":["https://orcid.org/0000-0002-5153-8092"]},"institutions":[{"id":"https://openalex.org/I84027002","display_name":"Leeds Beckett University","ror":"https://ror.org/02xsh5r57","country_code":"GB","type":"education","lineage":["https://openalex.org/I84027002"]}],"countries":["GB"],"is_corresponding":true,"raw_author_name":"Siobhan McHugh","raw_affiliation_strings":["Leeds Beckett University, PD402, Portland Building, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK. Siobhan.McHugh@leedsbeckett.ac.uk","Leeds Beckett University, PD402, Portland Building, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Leeds Beckett University, PD402, Portland Building, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK. Siobhan.McHugh@leedsbeckett.ac.uk","institution_ids":["https://openalex.org/I84027002"]},{"raw_affiliation_string":"Leeds Beckett University, PD402, Portland Building, Leeds Beckett University, City Campus, Leeds, LS1 3HE, UK","institution_ids":["https://openalex.org/I84027002"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5026964466","display_name":"Gemma Louch","orcid":"https://orcid.org/0000-0001-6946-3693","observed_orcids":["https://orcid.org/0000-0001-6946-3693"]},"institutions":[{"id":"https://openalex.org/I130828816","display_name":"University of Leeds","ror":"https://ror.org/024mrxd33","country_code":"GB","type":"education","lineage":["https://openalex.org/I130828816"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Gemma Louch","raw_affiliation_strings":["School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK","institution_ids":["https://openalex.org/I130828816"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5072700805","display_name":"Katherine Ludwin","orcid":"https://orcid.org/0000-0002-0750-9577","observed_orcids":["https://orcid.org/0000-0002-0750-9577"]},"institutions":[{"id":"https://openalex.org/I4210111466","display_name":"Midlands Partnership NHS Foundation Trust","ror":"https://ror.org/01vf6n447","country_code":"GB","type":"healthcare","lineage":["https://openalex.org/I4210111466"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Katherine Ludwin","raw_affiliation_strings":["Midlands Partnership NHS Foundation Trust, Stafford, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Midlands Partnership NHS Foundation Trust, Stafford, UK","institution_ids":["https://openalex.org/I4210111466"]}]},{"author_position":"middle","author":{"id":"https://openalex.org/A5070501275","display_name":"Laura Sheard","orcid":"https://orcid.org/0000-0002-9241-8361","observed_orcids":["https://orcid.org/0000-0002-9241-8361"]},"institutions":[{"id":"https://openalex.org/I52099693","display_name":"University of York","ror":"https://ror.org/04m01e293","country_code":"GB","type":"education","lineage":["https://openalex.org/I52099693"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Laura Sheard","raw_affiliation_strings":["Department of Health Sciences, University of York, York, YO10 5DD, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"Department of Health Sciences, University of York, York, YO10 5DD, UK","institution_ids":["https://openalex.org/I52099693"]}]},{"author_position":"last","author":{"id":"https://openalex.org/A5028255839","display_name":"Jane Kathryn O'Hara","orcid":"https://orcid.org/0000-0001-5551-9975","observed_orcids":["https://orcid.org/0000-0001-5551-9975"]},"institutions":[{"id":"https://openalex.org/I241749","display_name":"University of Cambridge","ror":"https://ror.org/013meh722","country_code":"GB","type":"education","lineage":["https://openalex.org/I241749"]}],"countries":["GB"],"is_corresponding":false,"raw_author_name":"Jane K. O\u2019Hara","raw_affiliation_strings":["The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Strangeways Research Laboratory, Cambridge, CB1 8RN, UK"],"raw_orcid":null,"affiliations":[{"raw_affiliation_string":"The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Strangeways Research Laboratory, Cambridge, CB1 8RN, UK","institution_ids":["https://openalex.org/I241749"]}]}],"institutions":[],"countries_distinct_count":1,"institutions_distinct_count":5,"corresponding_author_ids":["https://openalex.org/A5086152049"],"corresponding_institution_ids":["https://openalex.org/I84027002"],"apc_list":{"value":3190,"currency":"USD","value_usd":3190},"apc_paid":{"value":3190,"currency":"USD","value_usd":3190},"fwci":4.485,"has_fulltext":true,"cited_by_count":13,"citation_normalized_percentile":{"value":0.95526357,"is_in_top_1_percent":false,"is_in_top_10_percent":true},"cited_by_percentile_year":{"min":97,"max":99},"biblio":{"volume":"24","issue":"1","first_page":"1207","last_page":"1207"},"is_retracted":false,"is_paratext":false,"is_xpac":false,"primary_topic":{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9746000170707703,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},"topics":[{"id":"https://openalex.org/T10508","display_name":"Patient Safety and Medication Errors","score":0.9746000170707703,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T12871","display_name":"Healthcare Quality and Management","score":0.008899999782443047,"subfield":{"id":"https://openalex.org/subfields/2739","display_name":"Public Health, Environmental and Occupational Health"},"field":{"id":"https://openalex.org/fields/27","display_name":"Medicine"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}},{"id":"https://openalex.org/T13896","display_name":"Health Services Management and Policy","score":0.002899999963119626,"subfield":{"id":"https://openalex.org/subfields/3600","display_name":"General Health Professions"},"field":{"id":"https://openalex.org/fields/36","display_name":"Health Professions"},"domain":{"id":"https://openalex.org/domains/4","display_name":"Health Sciences"}}],"keywords":[{"id":"https://openalex.org/keywords/stakeholder-engagement","display_name":"stakeholder engagement","score":0.9089999794960022},{"id":"https://openalex.org/keywords/patient-and-public-involvement","display_name":"patient and public involvement","score":0.5789999961853027},{"id":"https://openalex.org/keywords/learning-from-incidents","display_name":"learning from incidents","score":0.656000018119812},{"id":"https://openalex.org/keywords/policy-documents","display_name":"policy documents","score":0.5809999704360962},{"id":"https://openalex.org/keywords/organizational-learning","display_name":"organizational learning","score":0.8259999752044678},{"id":"https://openalex.org/keywords/mental-health-services","display_name":"mental health services","score":0.8730000257492065},{"id":"https://openalex.org/keywords/acute-care-services","display_name":"acute care services","score":0.7379999756813049},{"id":"https://openalex.org/keywords/policy-framing","display_name":"policy framing","score":0.5950000286102295},{"id":"https://openalex.org/keywords/just-culture","display_name":"just culture","score":0.4410000145435333}],"concepts":[{"id":"https://openalex.org/C518773536","wikidata":"https://www.wikidata.org/wiki/Q918533","display_name":"Nursing research","level":2,"score":0.817349910736084},{"id":"https://openalex.org/C145642194","wikidata":"https://www.wikidata.org/wiki/Q870895","display_name":"Health informatics","level":3,"score":0.799285352230072},{"id":"https://openalex.org/C137992405","wikidata":"https://www.wikidata.org/wiki/Q1137608","display_name":"Health administration","level":3,"score":0.7633157968521118},{"id":"https://openalex.org/C71924100","wikidata":"https://www.wikidata.org/wiki/Q11190","display_name":"Medicine","level":0,"score":0.7464002370834351},{"id":"https://openalex.org/C138816342","wikidata":"https://www.wikidata.org/wiki/Q189603","display_name":"Public health","level":2,"score":0.5805814862251282},{"id":"https://openalex.org/C190248442","wikidata":"https://www.wikidata.org/wiki/Q839486","display_name":"Qualitative research","level":2,"score":0.5527457594871521},{"id":"https://openalex.org/C159110408","wikidata":"https://www.wikidata.org/wiki/Q121176","display_name":"Nursing","level":1,"score":0.4495689272880554},{"id":"https://openalex.org/C2780877353","wikidata":"https://www.wikidata.org/wiki/Q2518253","display_name":"Health services research","level":3,"score":0.43424761295318604},{"id":"https://openalex.org/C144024400","wikidata":"https://www.wikidata.org/wiki/Q21201","display_name":"Sociology","level":0,"score":0.11051911115646362},{"id":"https://openalex.org/C36289849","wikidata":"https://www.wikidata.org/wiki/Q34749","display_name":"Social science","level":1,"score":0.0901578962802887}],"mesh":[{"descriptor_ui":"D004739","descriptor_name":"England","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006291","descriptor_name":"Health Policy","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D006801","descriptor_name":"Humans","qualifier_ui":null,"qualifier_name":null,"is_major_topic":false},{"descriptor_ui":"D013222","descriptor_name":"State Medicine","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true},{"descriptor_ui":"D036301","descriptor_name":"Qualitative Research","qualifier_ui":null,"qualifier_name":null,"is_major_topic":true}],"locations_count":7,"locations":[{"id":"doi:10.1186/s12913-024-11626-4","doi":"https://doi.org/10.1186/s12913-024-11626-4","is_oa":true,"landing_page_url":"https://doi.org/10.1186/s12913-024-11626-4","pdf_url":"https://bmchealthservres.biomedcentral.com/counter/pdf/10.1186/s12913-024-11626-4","source":{"id":"https://openalex.org/S12898181","display_name":"BMC Health Services Research","issn_l":"1472-6963","issn":["1472-6963"],"is_oa":true,"is_in_doaj":true,"is_core":true,"listed_in":["anvur-class-a","anvur-scientific","cwts-core","doaj","dongbi-b","doyens","fnege-4","jufo-2","ki-jl-1","medline","norway-1","oarl","poland-100","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320256","host_organization_name":"BioMed Central","host_organization_lineage":["https://openalex.org/P4310320256","https://openalex.org/P4310319965"],"host_organization_lineage_names":["BioMed Central","Springer Nature"],"type":"journal"},"license":"cc-by-nc-nd","license_id":"https://openalex.org/licenses/cc-by-nc-nd","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"BMC Health Services Research","raw_type":"journal-article"},{"id":"pmh:oai:pubmedcentral.nih.gov:11463144","doi":null,"is_oa":true,"landing_page_url":"https://www.ncbi.nlm.nih.gov/pmc/articles/11463144","pdf_url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC11463144/pdf/12913_2024_Article_11626.pdf","source":{"id":"https://openalex.org/S2764455111","display_name":"PubMed Central","issn_l":null,"issn":null,"is_oa":true,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":"cc-by-nc-nd","license_id":"https://openalex.org/licenses/cc-by-nc-nd","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"BMC Health Serv Res","raw_type":"Text"},{"id":"pmid:39385114","doi":null,"is_oa":false,"landing_page_url":"https://pubmed.ncbi.nlm.nih.gov/39385114","pdf_url":null,"source":{"id":"https://openalex.org/S4306525036","display_name":"PubMed","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I1299303238","host_organization_name":"National Institutes of Health","host_organization_lineage":["https://openalex.org/I1299303238"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"BMC health services research","raw_type":"Journal Article"},{"id":"pmh:oai:eprints.leedsbeckett.ac.uk:11447","doi":null,"is_oa":true,"landing_page_url":"https://eprints.leedsbeckett.ac.uk/view/creators/McHugh=3AS=3A=3A.html>","pdf_url":"https://eprints.leedsbeckett.ac.uk/id/eprint/11447/1/InvolvementInSeriousIncidentInvestigationsAQualitativeDocumentaryAnalysisOfNhsTrustPoliciesInEnglandPV-MCHUGH.pdf","source":{"id":"https://openalex.org/S4306400805","display_name":"Leeds Beckett Repository (Leeds Beckett University)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I84027002","host_organization_name":"Leeds Beckett University","host_organization_lineage":["https://openalex.org/I84027002"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"acceptedVersion","is_accepted":true,"is_published":false,"raw_source_name":null,"raw_type":"Article"},{"id":"pmh:oai:eprints.whiterose.ac.uk:218581","doi":null,"is_oa":true,"landing_page_url":"https://orcid.org/0000-0001-6946-3693>,","pdf_url":"https://eprints.whiterose.ac.uk/218581/1/s12913-024-11626-4.pdf","source":{"id":"https://openalex.org/S4306400854","display_name":"White Rose Research Online (University of Leeds, The University of Sheffield, University of York)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I2800616092","host_organization_name":"White Rose University Consortium","host_organization_lineage":["https://openalex.org/I2800616092"],"host_organization_lineage_names":[],"type":"repository"},"license":null,"license_id":null,"version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":null,"raw_type":"Article"},{"id":"pmh:oai:www.repository.cam.ac.uk:1810/374795","doi":null,"is_oa":true,"landing_page_url":"https://www.repository.cam.ac.uk/handle/1810/374795","pdf_url":"https://www.repository.cam.ac.uk/bitstreams/edcf68ed-824d-4c4f-bc3a-90d53a55ac8f/download","source":{"id":"https://openalex.org/S4306401777","display_name":"Apollo (University of Cambridge)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":"https://openalex.org/I241749","host_organization_name":"University of Cambridge","host_organization_lineage":["https://openalex.org/I241749"],"host_organization_lineage_names":[],"type":"repository"},"license":"cc-by-nc-nd","license_id":"https://openalex.org/licenses/cc-by-nc-nd","version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":null,"raw_type":"Article"},{"id":"pmh:oai:doaj.org/article:7257a0edec2040baa016894b145932f9","doi":null,"is_oa":true,"landing_page_url":"https://doaj.org/article/7257a0edec2040baa016894b145932f9","pdf_url":null,"source":{"id":"https://openalex.org/S4306401280","display_name":"DOAJ (DOAJ: Directory of Open Access Journals)","issn_l":null,"issn":null,"is_oa":false,"is_in_doaj":false,"is_core":false,"listed_in":[],"host_organization":null,"host_organization_name":null,"host_organization_lineage":[],"host_organization_lineage_names":[],"type":"repository"},"license":"cc-by-sa","license_id":"https://openalex.org/licenses/cc-by-sa","version":"submittedVersion","is_accepted":false,"is_published":false,"raw_source_name":"BMC Health Services Research, Vol 24, Iss 1, Pp 1-11 (2024)","raw_type":"article"}],"best_oa_location":{"id":"doi:10.1186/s12913-024-11626-4","doi":"https://doi.org/10.1186/s12913-024-11626-4","is_oa":true,"landing_page_url":"https://doi.org/10.1186/s12913-024-11626-4","pdf_url":"https://bmchealthservres.biomedcentral.com/counter/pdf/10.1186/s12913-024-11626-4","source":{"id":"https://openalex.org/S12898181","display_name":"BMC Health Services Research","issn_l":"1472-6963","issn":["1472-6963"],"is_oa":true,"is_in_doaj":true,"is_core":true,"listed_in":["anvur-class-a","anvur-scientific","cwts-core","doaj","dongbi-b","doyens","fnege-4","jufo-2","ki-jl-1","medline","norway-1","oarl","poland-100","russia-white-list-1","vabb-shw"],"host_organization":"https://openalex.org/P4310320256","host_organization_name":"BioMed Central","host_organization_lineage":["https://openalex.org/P4310320256","https://openalex.org/P4310319965"],"host_organization_lineage_names":["BioMed Central","Springer Nature"],"type":"journal"},"license":"cc-by-nc-nd","license_id":"https://openalex.org/licenses/cc-by-nc-nd","version":"publishedVersion","is_accepted":true,"is_published":true,"raw_source_name":"BMC Health Services Research","raw_type":"journal-article"},"sustainable_development_goals":[{"score":0.6601999998092651,"display_name":"Peace, justice, and strong institutions","id":"https://metadata.un.org/sdg/16"},{"score":0.4000000059604645,"display_name":"Good health and well-being","id":"https://metadata.un.org/sdg/3"}],"study_designs":[],"awards":[{"id":"https://openalex.org/G2728229794","display_name":null,"funder_award_id":"18/10/02","funder_id":"https://openalex.org/F4320319990","funder_display_name":"National Institute for Health and Care Research"},{"id":"https://openalex.org/G4951984906","display_name":null,"funder_award_id":"18/10/02","funder_id":"https://openalex.org/F4320334785","funder_display_name":"Health Services and Delivery Research Programme"}],"funders":[{"id":"https://openalex.org/F4320319990","display_name":"National Institute for Health and Care Research","ror":"https://ror.org/0187kwz08"},{"id":"https://openalex.org/F4320319994","display_name":"Department of Health and Social Care","ror":"https://ror.org/03sbpja79"},{"id":"https://openalex.org/F4320328043","display_name":"Patient Safety Translational Research Centre","ror":null},{"id":"https://openalex.org/F4320334785","display_name":"Health Services and Delivery Research Programme","ror":"https://ror.org/0187kwz08"}],"has_content":{"pdf":true,"grobid_xml":true},"content_urls":{"pdf":"https://content.openalex.org/works/W4403255461.pdf","grobid_xml":"https://content.openalex.org/works/W4403255461.grobid-xml"},"referenced_works_count":22,"referenced_works":["https://openalex.org/W164031750","https://openalex.org/W186914685","https://openalex.org/W1936622395","https://openalex.org/W1983981789","https://openalex.org/W1998001663","https://openalex.org/W2045563369","https://openalex.org/W2049611483","https://openalex.org/W2111128742","https://openalex.org/W2167423126","https://openalex.org/W2167445993","https://openalex.org/W2335573370","https://openalex.org/W2883398855","https://openalex.org/W2925082881","https://openalex.org/W2956140667","https://openalex.org/W3012094248","https://openalex.org/W4205174519","https://openalex.org/W4221111944","https://openalex.org/W4239359318","https://openalex.org/W4252633962","https://openalex.org/W4281606269","https://openalex.org/W4290101121","https://openalex.org/W4297902553"],"related_works":["https://openalex.org/W4415507273","https://openalex.org/W4389321469","https://openalex.org/W4407111178","https://openalex.org/W3174210807","https://openalex.org/W7032946474","https://openalex.org/W6966881592","https://openalex.org/W4410233823","https://openalex.org/W3029869261","https://openalex.org/W4409689374","https://openalex.org/W4406307565"],"abstract_inverted_index":{"BACKGROUND:":[0],"The":[1],"considered":[2],"shift":[3],"from":[4,15,216,296],"individual":[5],"blame":[6],"and":[7,28,41,46,88,96,140,187,232,253,258,269,297,301,315,339,365,372],"sanctions":[8],"towards":[9],"a":[10,50,112,160,197,223,248,267,283],"commitment":[11],"to":[12,21,38,52,66,97,122,172,212,294,327,356,376,385],"system-wide":[13],"learning":[14,215,338],"incidents":[16,78,181,218],"in":[17,61,70,81,92,126,129,135,144,147,167,310,321,359],"healthcare":[18,382],"has":[19],"led":[20],"increased":[22],"understanding":[23,53,329,347],"of":[24,31,73,104,115,176,240,244,251,255,303,312,330,351,381],"both":[25,370],"the":[26,54,68,93,124,145,227,299,313,341,357,361],"moral":[27,204,314],"epistemic":[29,206,316],"importance":[30],"involving":[32],"those":[33,74,177,304],"affected.":[34,305],"It":[35],"is":[36,79,133,288,363,367],"important":[37],"understand":[39],"whether":[40],"how":[42,348],"local":[43,117,371],"policy":[44,55,84,105,136,168,311,352,374,383],"describes":[45],"prompts":[47],"involvement":[48,72,128,158,175,186,320],"with":[49,298],"view":[51],"landscape":[56],"for":[57,100,106,208,318,336,343,369],"serious":[58,77,118,130,180,217,322],"incident":[59,82,119,131,323],"investigations":[60,132,281,324],"healthcare.":[62],"This":[63],"study":[64],"aimed":[65],"explore":[67,123],"way":[69,125,358],"which":[71,127,286,360],"affected":[75,178],"by":[76,164,179,277],"represented":[80,134],"investigation":[83,120],"documents":[85,137,353,384],"across":[86,138],"acute":[87,139],"mental":[89,141],"health":[90,142],"services":[91,143],"English":[94],"NHS,":[95],"identify":[98],"guidance":[99],"more":[101,209,235,378],"effective":[102,308,379],"construction":[103,239,380],"meaningful":[107,387],"involvement.":[108],"METHODS:":[109],"We":[110],"conducted":[111],"documentary":[113],"analysis":[114],"43":[116],"policies":[121],"NHS":[146],"England.":[148],"RESULTS:":[149],"Three":[150],"headline":[151],"findings":[152],"were":[153,189,354],"generated.":[154],"First,":[155],"we":[156],"identified":[157],"as":[159,191,196,222,238,282],"concept":[161],"was":[162,182,194,219,230,234,262,275],"conspicuous":[163],"its":[165,331],"absence":[166],"documents.":[169],"Direct":[170],"reference":[171],"support":[173,188],"or":[174,205],"lacking.":[183],"Even":[184],"where":[185],"recognised":[190],"important,":[192],"this":[193,274],"described":[195,221],"passive":[198],"process":[199,250],"rather":[200,246,290],"than":[201,247,291],"there":[202,261],"being":[203],"justification":[207],"active":[210],"contribution":[211],"learning.":[213],"Second,":[214],"typically":[220],"high":[224],"priority":[225],"but":[226,272],"language":[228],"used":[229],"unclear":[231],"'learning'":[233],"often":[236],"positioned":[237],"an":[241,263,292],"arbitrary":[242],"set":[243],"recommendations":[245],"participatory":[249],"deconstruction":[252],"reconstruction":[254],"specific":[256],"systems":[257],"processes.":[259],"Third,":[260],"emphasis":[264],"placed":[265],"on":[266],"just":[268],"open":[270],"culture":[271],"paradoxically":[273],"reinforced":[276],"expected":[278],"compliance,":[279],"positioning":[280],"tool":[284],"through":[285],"action":[287],"governed":[289],"opportunity":[293],"learn":[295],"experiences":[300],"expertise":[302],"CONCLUSIONS:":[306],"More":[307],"representation":[309],"reasons":[317],"stakeholder":[319],"may":[325],"lead":[326],"better":[328],"importance,":[332],"thus":[333],"increasing":[334],"potential":[335,342],"organisational":[337],"reducing":[340],"compounded":[344],"harm.":[345],"Moreover,":[346],"structural":[349],"elements":[350],"central":[355],"document":[362],"framed":[364],"received":[366],"significant":[368],"national":[373],"makers":[375],"enable":[377],"prompt":[386],"action.":[388]},"counts_by_year":[{"year":2026,"cited_by_count":8},{"year":2025,"cited_by_count":5}],"updated_date":"2026-11-07T11:25:07.637180","created_date":"2024-10-10T00:00:00"}