London Protocol Framework & Process
Clinical incident review should do more than document what went wrong. It should help healthcare organisations understand the care delivery problems and contributory factors behind an incident, support learning, and reduce the risk of future harm.
The London Protocol is a structured method for reviewing serious clinical incidents in order to identify the healthcare system issues that contributed to patient harm. Used within NSW Health as an approved incident review method, it helps teams examine incidents in a more systematic, defensible, and improvement-focused way.
Why the London Protocol matters
Effective clinical incident review should do more than identify the immediate error or breakdown. It should help organisations:
understand the care delivery problems that occurred
identify the contributory factors behind patient harm
support learning and improvement rather than blame
strengthen patient safety and reduce the risk of recurrence
The London Protocol Framework
The London Protocol is a structured clinical incident review method developed in the UK and used internationally, including within Australia and New Zealand, to examine care delivery problems and contributory factors behind patient harm.
It is a two-stage process. First, it identifies the care delivery problems that may have occurred during the care process. Second, it identifies the contributory factors that were present at the time of the incident and helped make those problems possible.
Care delivery problems
Care delivery problems are problems that arise in the process of care, usually actions or omissions by staff.
Two essential features define a care delivery problem:
care deviated beyond safe limits of practice
the deviation had at least a potential direct or indirect effect on the adverse outcome for the patient, member of staff, or general public
Contributory factors
Many factors may contribute to a single care delivery problem. These may include:
Patient factors — for example, where a patient was distressed or unable to understand instructions
Task and technology factors — for example, poor equipment design or the absence of protocols
Individual factors — for example, lack of knowledge or experience among staff
Team factors — for example, poor communication between staff
Work environment factors — for example, high workload or inadequate staffing
By examining both care delivery problems and contributory factors, the London Protocol helps organisations build a clearer understanding of how and why a clinical incident occurred, and what should change to improve patient safety.
The London Protocol process
The London Protocol provides a structured approach to clinical incident review and follow-up action. In NSW Health materials, the process is framed around three central questions: What happened? Why did it happen? What action can we take to prevent it happening again?
It includes:
applying the London Protocol framework
preliminary scoping
avoiding conflicts of interest
conducting incident reviews
identifying care delivery problems
identifying and assessing contributory factors
validating findings
verifying the depth and sufficiency of analysis
ensuring actions are practical and sustainable
reporting and communications
In practice, this means taking a more disciplined approach to clinical incident review: clarifying scope early, examining care delivery problems and contributory factors rigorously, testing whether the analysis is deep enough, and ensuring that actions address not only the immediate incident but the conditions that allowed it to occur.
Why clinical incident reviews often fall short in practice
Clinical incident reviews often focus too narrowly on the immediate event or the actions of individuals involved. That may help explain what happened in the moment, but it can miss the wider patient, task, team, environmental, and organisational conditions that contributed to the incident.
Without a clear framework, reviews can become inconsistent, overly blame-focused, or limited to surface-level actions. A stronger approach requires structure, disciplined inquiry, and attention to both care delivery problems and contributory factors.
How this framework is used in Columbo
The London Protocol can be selected within Columbo as one approach to clinical incident review. Columbo helps apply clinical review frameworks in a more structured and scalable way through adaptive interviews, evidence analysis, traceable outputs, and workflow support.
Use the London Protocol in practice
Whether you want to strengthen your clinical incident review approach directly or use the London Protocol within Columbo, we can help.