Identify. Investigate. Prevent.
Independent clinical investigations to establish what happened, why it happened, and what must change to prevent recurrence.
Our mission
We identify, investigate and prevent adverse clinical events.
We examine clinical events, adverse outcomes and underlying system weaknesses to establish what happened, why it happened, and how the risk of recurrence can be reduced.
Our work is independent, evidence-led and directed towards safer clinical care.
Identify
Recognise the signals. Surface the risk.
Identify emerging clinical risks, adverse events and patterns of potential harm — including signals missed, minimised or not escalated through conventional clinical processes.
We use structured preliminary reviews, clinical record analysis and signal-detection methods to determine what may be going wrong and whether further investigation is warranted.
Methods and services
- FIRST-PASS — Preliminary Clinical Safety Review
- PASS+ — Detailed Patient-Adaptive Safety Review with Signals Trajectory
- CORA — Clinical Observation & Risk Analyser
Investigate
Establish what happened. Determine why.
Reconstruct the clinical episode using contemporaneous evidence, examining clinical observations, decisions, actions, communication and escalation across the course of care.
We assess what was known, what was reasonably knowable, and whether the clinical response was appropriate at the time — without relying on hindsight.
Methods and services
- CASE — Clinical Assessment & Systems-Level Evaluation
- Independent Clinical Investigations
- Clinical Integrity and Evidence Assessment
Prevent
Understand the failure. Strengthen the safeguards.
Identify the conditions that allow adverse clinical events to occur or recur, including weaknesses in clinical governance, systems, decision-making, communication and risk controls.
We recommend corrective measures and, where commissioned, independently assess whether safeguards have been implemented and are operating effectively.
Methods and services
- Behavioural & Systems Viability
- Clinical Process Re-engineering
- Clinical Data & AI Integrity
- Clinical Governance & Control Assurance
Our approach
Beyond what the record says.
Standard clinical review examines what the record says. CID investigates whether the record reflects the clinical reality — and what the differences reveal.
Princeton Lee’s Clinical Investigation Division conducts independent, forensically structured investigations of clinical events, adverse outcomes and patient safety concerns.
We reconstruct clinical episodes from available evidence and examine the integrity of clinical systems, conduct and decision-making.
Our investigations look beyond individual actions to understand the wider conditions in which clinical decisions were made, risk signals were interpreted, and responses were carried out.
We do not simply ask whether a protocol existed or whether a record was completed.
We examine whether the right thing was done, given what was reasonably knowable at the time, and whether systemic, behavioural or decision-making failures contributed to the outcome.
Our findings are evidence-based, structured and independently determined.
The commissioning party does not determine the findings.
Clinical assurance — the evidence
Australia’s clinical error burden is large, measurable — and substantially preventable.
Adverse clinical events are not always isolated or unpredictable. Many arise from recurring patterns of diagnostic error, communication breakdown, delayed escalation, decision-making weaknesses and ineffective system controls.
These patterns may be visible in clinical records and operational data long before their significance is recognised.
Estimated annually in Australian clinical settings, with a substantial proportion considered preventable.
Estimated annually from diagnostic errors, including fatal outcomes.
Estimated annual medication-related admissions, many considered potentially preventable.
Estimated cost associated with medication-related hospital admissions across Australia.
1. Scott IA, Crock C. Diagnostic error: incidence, impacts, causes and preventive strategies. Med J Aust 2020; 213(7). doi:10.5694/mja2.50771
2. Lim R, Kalisch Ellett LM, Semple S, Roughead EE. The extent of medication-related hospital admissions in Australia: a review from 1988 to 2021. Drug Saf 2022; 45(3): 249–257. doi:10.1007/s40264-021-01144-1
The patterns are recognisable.
Read the researchCognitive and decision-making failures
Anchoring bias, premature diagnostic closure and failures to reconsider clinical interpretations when new evidence emerges.
Communication and information failures
Incomplete handovers, fragmented clinical information, documentation omissions and failures to communicate emerging risks.
Systems and response failures
Ineffective escalation pathways, inadequate monitoring, delayed intervention and operational controls that fail to recognise or respond to deterioration.
These are not simply failures of documentation or compliance. They are failures in the way clinical systems detect, interpret, communicate and respond to risk.
Our methods are designed to identify these patterns, investigate their causes and inform measures to prevent recurrence.
Our approachThe framework
CASE.
Six dimensions.
One complete picture.
The Clinical Assessment & Systems-Level Evaluation framework examines clinical care across six interconnected dimensions.
It reconstructs what occurred, assesses how decisions and responses developed, and identifies where clinical systems, conduct or decision-making may have failed.
01Detection
Did the clinical environment recognise relevant signs of deterioration, abnormality or emerging risk, taking account of the individual patient’s circumstances?
02Interpretation
Were clinical observations, test results and other available evidence correctly interpreted and incorporated into ongoing clinical assessment and decision-making?
03Response Latency
Were appropriate responses initiated within clinically relevant timeframes, and what do delays reveal about the clinical and organisational environment?
04Decision Integrity
Were clinical decisions reasonable in light of the evidence available at the time, including what was reasonably knowable, without relying on hindsight?
05Escalation Integrity
Did escalation pathways function as intended, and were clinical risks communicated, acknowledged and acted upon appropriately?
06Governance & Disclosure
Do clinical records and subsequent accounts accurately reflect the contemporaneous evidence, clinical decisions, care provided and relevant disclosure obligations?
From evidence to findings.
CASE brings these dimensions together to produce an integrated assessment of the clinical episode and the conditions in which care was delivered. Its outputs may include:
- Summary of Findings
- Detailed Clinical Analysis
- Integrated Findings
- Referral and Recommended Next Actions
- Patient Safety and Systems Improvement Recommendations
Independence & integrity
The evidence determines the findings.
CID is the dedicated clinical investigation practice of Princeton Lee Partners.
Our investigations are conducted independently, with findings determined by the available evidence rather than the interests of the commissioning party.
We distinguish established facts from interpretation, uncertainty and matters requiring further investigation.
Our work is guided by procedural fairness, intellectual honesty and professional accountability.
The commissioning party does not determine the findings.
Confidential enquiries
Concerned about a clinical event, adverse outcome or patient safety risk?
An investigation begins by understanding the circumstances, the available evidence and the questions that need to be answered.
CID offers confidential preliminary enquiries and defined-scope assessments to help determine an appropriate course of action.
Clinical Investigation Division
An independent investigative practice of Princeton Lee Partners.
Identify. Investigate. Prevent.