Root cause analysis in action

This document contains tools and examples to help you complete a significant event audit. As part of a significant event audit you will be thinking about the reasons why an event happened and these tools can help you identify the root cause.

Root cause analysis is a collective term and this document looks at different approaches to uncover a root cause, including

• The 5 whys
• Contributory factors checklist
• Cause and effect diagram, also known as a fishbone diagram.

This document was first published in January 2020 and last updated in September 2025.

We also have blank templates for the contributory factors checklist and fishbone diagram, which you can find below in the related resources.