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Investigation of Deaths & Serious Incidents in Mental Health Services

Learning from deaths in Mental Health Services Using the National Mortality Review Tool

Dr Elena Baker-Glenn
, Consultant Liaison Psychiatrist, Cambridgeshire and Peterborough NHS Foundation Trust, Development Lead, Care Review Tool, The Royal College of Psychiatrists 

The presentation will focus on the work of the mortality review group at the Royal College of Psychiatrists. It will cover the relevant background information about learning from deaths and why a specific tool was required for mental health trusts. It will describe the development of the tool and the reason for certain red flags being selected. It will also cover the difference between an investigation and case note review. Potential learning and limitations from the reviews will be considered, and suggestions for ongoing work will be discussed.

Full PowerPoint Presentation



Effective investigation: tools, principles and practice
Sue Bos,
Independent specialist in investigation, Patient Safety Science 

Pre-event abstract
Effective investigation: tools, principles and practice
Safety is not rocket science…..but it is a science!
Systems-based investigations make a unique contribution to patient safety. Effective investigation is based on the examination of human error and a robust methodology for analysing systemic weaknesses that cause mistakes resulting in serious harm to patients. 
The session will introduce delegates to the fundamental principles underpinning the effective investigation of deaths in mental health and learning disability services. The aim is to consider the identification of these serious incidents and to outline key steps in the processes to be followed by trusts in order to deliver reliable, credible, proportionate and actionable investigations. Delegates will have the opportunity to pick up tips on gathering information, interviewing staff and writing the investigation report. 

Full PowerPoint Presentation


Learning from complaints about serious incidents in mental health services
Alex Robertson
, Executive Director of Strategy & Operations, Parliamentary and Health Service Ombudsman

Pre-event abstract
How can professionals, patients, families and organisations learn from when things go wrong in mental health services? This session will explore how serious incidents, and the complaints that follow them, can provide invaluable insights to help improve the quality and safety mental health care. Using a case study where a NHS mental health trust allowed service failings to recur, this session will consider the culture, skills, leadership and accountability necessary to ensure that learning takes place and prevent the same mistakes from happening again.

Full PowerPoint Presentation

 

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