Investigation of Deaths & Serious Incidents in Mental Health Services
Friday 10 February 2017
De Vere West One, London
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“When things go wrong, it is important for healthcare professionals and organisations to learn lessons and make sure the same mistakes are not repeated. Nowhere is this more important than when someone dies. Following the NHS England commissioned report on the investigation of deaths at Southern Health, we are looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. We also want to assess whether opportunities to prevent deaths have been missed. Findings from our review are due to be published later this year.” Care Quality Commission 2016
This conference will focus on improving the quality of investigations of deaths and serious incidents in mental health services, learning from Mazars Report into Southern Health and implementing the recommendations of the CQC review into how NHS trusts investigate and learn from death published on Tuesday 13 December 2016.
Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.” He added that “there is not a single NHS trust that is getting it completely right currently” HSJ December 2016
“Learning from deaths needs much greater priority across the health and social care system. Without this, opportunities to improve care for future patients will continue to be missed…. Healthcare providers should have a consistent approach to identifying and reporting, investigating and learning from the deaths of people using their services, and when appropriate, sharing this information with other services involved in a patient’s care before their death… Bereaved relatives and carers must always be treated as equal partners and receive an honest and caring response from health and social care providers. … Reviews and investigations need to be carried out to a high quality, with a focus on system analysis rather than individual errors.” Care Quality Commission Dec 2016
The conference will also look at implementing the five recommendations for improvement in the investigation of serious incidents as identified by the Care Quality Commission in July 2016. Through national updates, practical case studies and extended masterclasses, the conference will provide a step by step guide to high quality investigation and learning from deaths of people who received care from their mental health service.
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