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Critical incident analysis

These tools can be used by leaders, managers, supervisors and social workers.

Strong and Clear Social Work Framework

As an effective leader you should acknowledge that mistakes happen and see them as a learning opportunity. This can help avoid defensive reactions.

Critical incidents are often shocking and impact on the wellbeing of staff and the functioning of the organisation. They can also be effective sources of learning, as the organisational response often includes a formal review of the incident, the response and the outcome.

Examples of reviews in social care are: 

  • local child safeguarding practice review 
  • safeguarding adults reviews 
  • independent investigations into homicides (mental health homicide reviews) 
  • inquests following suicide

Using these review processes to identify learning will improve social care practice, both individually and collectively. Find out more about these review processes in the Working together to safeguard children guidance and the Care and support guidance guidance for adult social care. 

Responding to critical incidents

Critical incidents are not always serious or involve dangerous scenarios. Even if not dangerous, critical incidents provide valuable insights as a learning opportunity. 

When critical incidents occur, your response as a leader is important as it sets an example for others. Experiencing emotional response to critical incidents is natural. Managing your emotional response as a leader will support staff to manage their own emotions. Reflective leadership is essential to ensure learnings are taken from critical incidents. 

​​​​​​​​​​​​​Critical incident analysis

Analysing critical incidents is important. You can use this framework to analyse critical incidents.

Account

Describe an incident that was particularly challenging, pertinent, or revelatory.

Ask yourself:

  • what happened? 
  • what was the context? 
  • what was the purpose of the work? 

Response

Consider your initial response to the scenario.

Ask yourself:

  • what was your response including your emotional reaction? 
  • what was the response of others around you? 
  • was this as expected or different? 
  • did you rush to seek an explanation or apportion blame?

Dilemma

Asking questions to find different explanations for the dilemma, exploring theories, values, assumptions, and defensive mechanisms and biases.

Ask yourself:

  • what dilemmas were highlighted by this scenario? 
  • what are the implications for practice, including working inter-professionally? 
  • could you hear the voice of the child represented in the explanations? 
  • is there evidence of professional curiosity around risks and decision-making? 
  • how were risks factors understood and assessed? 

Learning 

Reflect on what you have learned.

Ask yourself:

  • what have you learned about the practice of your organisation and other organisations around you? 
  • what have you learned about yourself and others in relation to thinking, decision-making, and emotional reactions? 
  • did all partners share the right information at the right time to ensure the person’s safety 
  • could we have been more professionally curious about what was going on for this person/child and their context? 
  • did we pay enough attention to the adult or child’s voice throughout? 
  • what might help enhance your learning, and who or what can you draw on to assist you?

Outcomes

Considering the implication for future practice.

Ask yourself:

  • what change could result from this incident? 
  • what are the outcomes for the individuals and the organisation? 
  • what has this taught you?

When investigating a critical incident, culture plays a role. Research (Mueller in references) shows that staff anxiety may prevent learning.

Serious incidents typically result from systemic factors rather than being the ‘fault’ of a single individual. Establishing psychological safety when discussing errors can prevent individuals being blamed.

Instead of concentrating on missed opportunities, identify: 

  • why opportunities were missed to prevent the error 
  • what prevented the system from detecting the error 
  • why curious questions were not asked by professionals as the events progressed 

Barriers to learning

Research on adult safeguarding reviews, and reviews in children’s social care, highlight some barriers to learning (see Preston-Shoot in references). Being aware of these will improve critical thinking and analysis.  

The barriers include: 

  • a start again culture - when reviews fail to build on previous learning with a tendency to start again rather than identify patterns
  • local focus - excessive attention on local issues rather than considering how policies and practices influence situations 
  • analytic depth - there is a need for deeper analysis to understand the why behind incidents
  • challenge assumptions - you should challenge assumptions and change efforts should use a systemic approach rather than a narrow focus on micro-processes 

Root cause analysis

Using a root cause analysis can help understand the underlying causes of a problem or situation.

Guidance on managing critical incidents related to child protection is available in working together to safeguard children. For adult protection, see the care and support guidance. 

Complaints also present an opportunity for growth and improvement. Complaints provide valuable insights into the quality of service offered. An open culture will encourage the voicing of complaints. It is essential to create an environment where you listen to complaints and act on them. 

The Ishikawa or fishbone diagram

A cause and effect diagram represented in the shape of a fish. The head represents the problem and the bones represent the causes.

The Ishikawa or fishbone diagram can be used to organise your ideas and theories about why something occurred. It visually represents what happened and can be used collaboratively with groups of stakeholders. It provides an interactive method for exploring an issue.

You can follow this step-by-step process:

1. What is the problem or incident you are trying to understand or solve? 

2. Identify the factors contributing to the problem. Start with 4 to 6 main factors and expand as needed. These categories are the ‘ribs of the fish’. Some examples of contributory factors are shown in the diagram. 

3. As a group, identify the possible causes of the problem, placing them in the categories where they fit best. 

4. Prioritise the causes you should address first. Select 1 to 3 causes that are most likely to solve the problem. Consider feasibility (for example, cost, support, time frame) and the likelihood of succeeding. 

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The resources have been developed by Research in Practice in collaboration with DfE.
Published: 27 February 2025
Last updated: 16 April 2025