Major failures in patient safety often lead to high profile inquiries set up to establish the facts, and to identify areas of improvement to prevent further failures. In order to learn from inquiries, we need to be able to identify if, and how, the inquiry process influences improvements.

Using a case study strategy, this research study examined the impact or influence of the Douglas Inquiry on KEMH’s clinical governance systems. The research focused on two areas that were highlighted in the final Inquiry report as requiring reform. These systems deal with the clinical credentialing and performance review and the involvement of consumers in care.

Several sources of data collection were employed. Firstly, document and archive analysis identified the procedures and processes employed by the Inquiry, and the changes that had occurred at the hospital. Secondly, semi-structured interviews ascertained participants’ perceptions of changes in clinical governance systems at KEMH post Inquiry, and the influence of the Inquiry on the changes that have taken place. The findings were then compared and with the literature.

The study conclusions identified critical factors within the Inquiry process, which influenced improvement in the clinical governance systems examined. Absence of one of these critical factors resulted in the Inquiry reinforcing existing barriers and thus, in those areas there was no change. Lewin’s (1951) model of change specifically informed the analytic process, with the outcome resulting in the development of a conceptual model of organisational clinical governance change.

This paper reports the results of this study and presents the conceptual model of change.


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