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Investigation of Deaths & Serious Incidents in Mental Health Services

This Conference is now Closed

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“The NQB guidance requires that all inpatient, outpatient and community patient deaths of people with severe mental illness (SMI) should be subject to case record review.”

NHS Improvement

“Through our well led inspections we have seen trusts that have made positive changes to ensure that learning from deaths is given the priority it deserves… However, the speed of progress varies, and our review indicates that problems with the culture of some organisations is preventing sufficient progress… We will continue to assess the progress trusts are making through our inspection and monitoring and to hold trusts to account when we find improvements are required… Alongside this, there needs to be continued support from the centre, including support for behaviours that encourage more openness and learning across the NHS, clearer guidance for community and mental health trusts, and a more focused consideration of the progress being made on reviews and investigations of deaths of people with mental health problems or a learning disability which was highlighted as a priority in our original thematic review.”

Professor Ted Baker, CQC’s Chief Inspector of Hospitals March 2019

This conference focuses on  Improving the Quality & Learning from Investigation of Deaths & Serious Incidents in Mental Health Services. Through national updates, practical case studies and extended sessions, 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. The conference will also look at effective implementation of the November 2018 National Mortality Care Review Tool developed by the Royal College of Psychiatrists. “The Care Review Tool is suitable for supporting mortality reviews for patients who were under the care of mental health Trusts and it can be adapted for use by joint mental health and community Trusts… The tool allows explicit judgements around a patient’s care to be made, with a score given for each phase of care. The aim of this tool is to make it possible for Trusts to screen all deaths of patients in contact with mental health services and, through thematic analysis of a number of completed forms, to: 1. Determine areas of good care that can be recognised and further developed 2. Recognise areas where care can be improved” Royal College of Psychiatrists November 2018

This conference will enable you to:

  • Network with colleagues who are working to improve serious incident investigation, mortality review and learning from deaths in Mental Health services
  • Learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool
  • Reflect on national developments and learning
  • Improve the way you involve and engage families and carers in the investigation process
  • Develop your skills in incident investigation and mortality review
  • Understand how you can improve serious incident investigation and understand the recent changes to the NHS Improvement Serious Incident Framework
  • Identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation
  • Understand how human factors, and simulation can help improve learning from serious incident investigation
  • Ensure you are up to date with the role of the coroner
  • Self assess and reflect on your own practice
  • Gain cpd accreditation points contributing to professional development and revalidation evidence

100% of delegates at our previous conference on this subject would recommend it to a colleague

Chair and Speakers Include:

Sean Duggan

Chief Executive
Mental Health Network

Dr Elena Baker-Glenn

Liaison Psychiatrist & Development Lead
Care Review Tool, The Royal College of Psychiatrists

Dr Chris Daly

Medical Director
Greater Manchester Mental Health NHS Foundation Trust

Exhibition & Sponsorship Packages

This conference offers a valuable opportunity for industry suppliers to personally meet with their target audience away from their workplace in an intimate environment where they will have time to talk and demonstrate the benefits of their products. High quality specialist audiences make having a presence at our events, whether it be a sponsored session, or an exhibition stand, a highly targeted and cost effective marketing channel.

Why Exhibit?

Having a presence at this event will give you the opportunity to:

  • Demonstrate your product, system or service
  • Network and engage face to face with your key audience
  • Generate new business leads
  • Gain exposure for your brand and raise the profile of your organisation
  • Understand the current needs of your audience and challenges they’re facing
  • Update your knowledge of national policy and local developments  


Contact Carolyn Goodbody for exhibition and sponsorship prices, or to discuss a tailored package to suit your needs and budget.

Supporting Organisations