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Six Steps to Root Cause Analysis

First published in 2002, the 3rd edition of ‘Six Steps to Root Cause Analysis’ is now available. Over 7,000 copies of the book have been sold, and a number of NHS organisations have adopted ‘Six Steps to RCA’ as their incident investigation manual for their staff.


The book sets out a straight forward framework for the conduct of an effective investigation. A range of tools and techniques are clearly described and the author provides the reader with useful reflections around particular aspects of the investigation process.

In this third edition of the book particular attention is given to

  • The preparation and planning of an investigation, including terms of reference
  • Creating analytical timelines
  • The investigative interview
  • The structured analysis of information gathered via the investigation process
  • Defining contributory factors and root causes to care / case management concerns
  • Designing SMART recommendations
  • Delivering a robust investigation report

The Author

Maria Dineen is an expert investigator of health and social care incidents. The breadth of her experience gained in investigating health and social care incidents since first practising in 1994 has ensured that ‘Six Steps to RCA’ is of everyday practical use.  

Maria Dineen designed the initial content framework for the root-cause analysis training delivered by England’s National Patient Safety Agency in 2002, much of which remains present in their contemporary workshops. She also worked closely with the NPSA’s development team in the content design of their root-cause analysis e-learning tool-kit.

As Managing Director, senior facilitator and consultant at Consequence UK, Maria supports health and social care organisations in service development and delivering change management programmes. Delegates of CUK workshops include senior investigations teams and new practitioners, and her consistently excellent workshop delivery has resulted in a solid base of regular clients and a growing business built on a reputation for pragmatic, empathetic and excellent training.