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Investigation of Deaths & Serious Incidents in Mental Health Services

Monday 16 September 2019
De Vere West One Conference Centre, London

Investigation of Deaths & Serious Incidents in Mental Health Services
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“Around 2.5 million people are in contact with secondary mental health, learning disabilities and autism services each year and the deaths of many patients will be unconnected to the care they received. But it is crucial that ways of improving services are learned from patients’ deaths.“ Dr Adrian James, Registrar, The Royal College of Psychiatrists, November 2018

“Learning from deaths is an essential part of quality improvement work for organisations.” The Mortality Review Tool Guidance, Royal College of Psychiatrists, November 2018

“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

“Care Quality Commission (CQC) inspections have shown good progress is being made by some NHS hospital trusts to implement national guidance on learning from deaths. However, failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed.” Care Quality Commission March 2019

“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

“We know there are problems, for example, with how incidents are investigated and learned from. In our recent engagement to find out how we can improve the Serious Incident framework, people told us they were concerned about: providers’ lack of capability and capacity to carry out good quality investigations; the tendency to use investigation for the wrong purposes; the generally poor approach to patient and family involvement; and the fact that actions to reduce risks after the completion of an investigation are too often ineffective. We know from the Care Quality Commission’s (CQC’s) review of how the NHS responds to and learns from the care provided to patients who die that too often problems with care are not identified and the bereaved, who may have concerns, are not sufficiently supported.” NHS Improvement December 2018

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 new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.” Caroline Dinenage, Care Minister 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

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