RIS-3119-TOM Iss 2.1

This document sets out requirements and guidance for the investigation of adverse events involving more than one duty holder so that system improvements necessary to prevent or reduce the likelihood of recurrence, or mitigate the consequences.

The diagram in Figure 19 which was published in version 2 of RIS-3119-TOM contained an error, in that the boxes under ‘Stage 2: Answer to question 2’ (‘Negligible’, ‘Low’, ‘Medium’, ‘High’) were reversed. This can lead the user to come to an incorrect conclusion as to the level of investigation to be undertaken. The diagram has been replaced in issue 2.1.