Independent, learning-focused investigations across health, justice and safeguarding — delivered with rigour, compassion and absolute integrity.
When an incident is serious, sensitive or high-profile, the stakes are human and organisational. Trust can be fragile. Scrutiny is real. And the right response needs to be calm, credible and fair.
At CPGB we undertake independent investigations that help organisations understand what happened, why it happened, and what needs to change to reduce the risk of harm happening again.
What We Do
We deliver independent investigations that are proportionate, evidence-led, and built for improvement — including investigations into patient safety incidents, complex safeguarding concerns, multi-agency failures, serious operational breakdowns, governance weaknesses and cultural issues.
We are an approved provider on the NHS England Independent Investigation Framework, delivering investigations aligned to national standards and statutory expectations.
Please note: The Independent Investigations framework is transitioning to the Independent Learning Responses Framework in approximately one year.
Any reports that can be published under the framework will be published on the NHS England Reviews and Reports page.
Our Investigation Capabilities
Independent Expert Investigation
Individual expert supporting a provider or service to undertake an in-house investigation, development needs assessment or independent chairing.
Partnership Investigation
Investigation in partnership with statutory processes including Domestic Homicide Reviews and Serious Case Reviews.
Local Care System Investigation
Review of local care systems between providers and commissioners, measuring against national guidance.
Health & Social Care & Partners Investigation
Complex investigations across health and multiple stakeholder organisation boundaries, reviewing patient journeys end to end.
Systematic Independent Investigation
High-profile investigations across geographical boundaries requiring multiple experts, instigated by significant concerns from regulatory bodies and stakeholders.
What an independent investigation is (and isn't)
Independent patient safety investigations in the NHS exist to generate insight for improvement — exploring care, treatment and system factors, and making recommendations that relevant organisations can act on.
They are not designed to apportion blame or liability, nor to determine fitness to practise or criminal issues (although other processes may run alongside).
When to bring CPGB in
Organisations typically engage us when they need:
- Independence that stands up to scrutiny (internal or external)
- A trauma-informed, relational approach that is rigorous without being punitive
- Clear findings that translate into practical, implementable improvement
- A team that can move confidently between frontline reality and board-level assurance
How we work
Clear, fair, and evidence-led.
Our investigations are trauma-informed and relational: we listen carefully, analyse thoroughly and act with integrity. In practice, our approach draws on methods commonly used in complex reviews, including:
- Engagement with stakeholders and services
- Document review and evidence testing
- A structured approach to voice and experience (for example: surveys, focus groups, stakeholder engagement)
- Triangulation to test themes and avoid single-source conclusions (including the use of a triangulation matrix where appropriate)
- Explicit attention to independence and conflicts of interest as part of governance
We also align to learning-focused principles seen in PSIRF: compassionate engagement, system-based learning approaches, proportionate responses, and supportive oversight that strengthens improvement.
What you get
Every commission is scoped to your Terms of Reference, but typical outputs include:
- A clear, structured report (findings + contributing factors + conclusions)
- Actionable recommendations that organisations with the power to change can implement
- A practical improvement and assurance view (what needs to change, who owns it, and how it can be tracked)
- A process that is respectful and transparent, especially when people are distressed or trust has been damaged
Information for Families
You don't have to carry this on your own.
When something serious happens in a healthcare, social care, or community setting, families often carry the greatest emotional weight. Independent investigations can feel daunting — especially when there are unanswered questions, or when trust has been shaken.
We approach every investigation with compassion, clarity and respect. Our aim is to make the process feel safe, transparent and manageable — and to ensure any learning leads to real improvement.
If you're involved as a family member and you're unsure what happens next, you can contact us. We will respond with clarity, compassion and honesty.
What an independent investigation is
An independent investigation is a structured way of understanding what happened, why it happened, and what can be learned — so organisations can improve and reduce the risk of similar harm happening again.
Our work is grounded in learning, compassion, transparency and improvement.
Your choices: how you can be involved
Family involvement is always shaped around your preference. Some families want to share their experience in detail; others prefer limited involvement or written communication. Some want to meet the investigator; others prefer to contribute through a representative. All approaches are respected.
If you choose to share your experience, you can do it in the way that feels most manageable for you:
- A conversation (in person or online)
- Written reflections
- Via a representative
There is no pressure to take part, and you can change your mind at any stage.
What you can expect from us
We know families need more than "a process". They need to feel heard, understood and supported. From the start, we will:
Explain what an independent investigation is, and what it can and cannot do
Offer a single point of contact, so you always know who to speak to
Agree how and when you would like updates
Communicate clearly, respectfully and without jargon
How we handle information
We handle sensitive information with care and confidentiality. When families share their experiences, we listen with empathy and professional curiosity, ensuring your perspective informs the investigation in a meaningful and balanced way.
We are transparent about how information is used, how findings are developed, and how learning is identified.
Where helpful, we can also explain the wider system context — because it can be hard to make sense of complex organisational or multi-agency factors while you're also dealing with the human impact.
What to expect during an investigation
We explain the purpose and the questions
At the start, we'll explain what we've been asked to explore and what the investigation is for.
We agree contact and updates
You'll be offered a single point of contact, and we'll agree together how and when you'd like to hear from us.
You choose how to share (if you want to)
Some families prefer a conversation, others prefer writing. There is no right or wrong approach — and there is no pressure to take part.
We keep you informed
Throughout the investigation we will keep you informed about progress and next steps.
We share learning at the end
When the work is complete, we'll offer you the opportunity to discuss the findings and ask questions.
What happens at the end
When the investigation is complete, we offer families the opportunity to:
- Discuss the findings
- Ask questions
- Understand the learning that has emerged
We recognise these conversations can be emotionally challenging. We approach them with sensitivity and respect. Our aim is not only to establish what happened, but to ensure the learning leads to meaningful, lasting improvement.
Why CPGB
What sets CPGB apart is the combination of clinical credibility, operational insight and commercial intelligence — paired with a values-driven approach that is rigorous, fair and deeply human.
Frequently Asked Questions
What is a PSIRF-aligned investigation?▼
PSIRF (Patient Safety Incident Response Framework) is the NHS framework for responding to patient safety incidents. Our investigations align to PSIRF principles: compassionate engagement, system-based learning, proportionate responses and supportive oversight that drives improvement rather than blame.
What types of investigations does CPGB Ltd undertake?▼
We undertake independent expert investigations, partnership investigations with statutory processes (such as DHRs and Serious Case Reviews), local care system investigations, multi-agency health and social care investigations, and high-profile systematic investigations across geographical boundaries.
How do you involve families in investigations?▼
Family involvement is shaped around each family's preference. Some families share their experience in detail, others prefer limited involvement or written communication. We offer a single point of contact, agree how and when families would like updates, and communicate clearly, respectfully and without jargon.
Are your investigators clinically qualified?▼
Yes. Our investigation team includes NMC registered nurses, GMC registered doctors and experienced forensic psychiatrists with frontline clinical experience across NHS mental health, offender health, community and acute services.
How long does an independent investigation take?▼
Timelines depend on complexity and terms of reference. A single-service review may take 8-12 weeks, while a complex multi-agency systematic investigation may take 6-12 months. We always agree realistic timescales at the outset.
Further reading
Deeper guidance on PSIRF practice, safeguarding reviews and independent investigation processes.
- PSIRF patient safety investigations: a practical guide
What compassionate, system-based PSIRF investigation looks like in practice.
- The NHS PSIRF investigation process explained
A step-by-step walk-through of PSIRF response from incident through to learning.
- Independent safeguarding reviews: what to expect
How independent reviews are commissioned, scoped and delivered with families at the centre.
- Section 42 safeguarding enquiries: a provider guide
Provider duties, evidence and process under the Care Act for Section 42 enquiries.
Commission an Investigation
If you're facing a serious incident, heightened scrutiny, or a complex multi-agency situation — we'll bring calm leadership, clear thinking, and an investigation process you can trust.