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Investigation of Deaths & Serious Incidents in Mental Health Services

Today’s conference, chaired by Dr Rajesh Nadkarni, looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services.  

Dr Rajesh Nadkarni

Medical Director
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust


Improving Standards of Serious Incident Reviews through Accreditation, and Using the National Mortality Review Tool

Dr Elena Baker-Glenn 
Liaison Psychiatrist 
Northamptonshire Healthcare NHS Foundation Trust
& Chair of SIRAN accreditation panel
Royal College of Psychiatrists

• The care review tool for mortality reviews in mental health Trusts
• ‘red-flag’ scenarios which should prompt further investigation
• Development of Principles and Standards for serious incident reviews
• Experience of the Serious Incident Review Accreditation Network to improve the investigation process and learning

Dr Elena Baker-Green started the day with a talk focusing on how we can improve standards of Serious Incident Reviews through accreditation, and use of the National Mortality Review Tool.  She gave a valuable insight into developments in serious incident reviews and management from the Royal College of Psychiatrists.

Looking at deaths & serious incidents from a user/family perspective

Richard West
Richard West is the father of David West who died aged 28 years whilst a patient under Southern Health NHS Foundation Trust


• a personal journey: how organisations could improve the investigation process from a family perspective
• how can we better involve relatives and carers?
• moving from reactive to proactive services

Suicidal risk factors, guidelines, standards of care and psychosocial assessments for patients

Ms Haifa Bin Haamed PhD
PhD researcher University of Sheffield 



• learning from suicidal cases among patients of chronic medical illness
• risk factors of suicidal and mental health conditions among  patients of chronic illness
• the learning from deaths dashboard & Structured Judgement Reviews
• sharing the learnings from deaths 
• guidelines/standards of care and suicidal assessments
• psychosocial assessments for patients with chronic illness

Haifa led the with a thorough session with key elements including but not limited to;

• Prevalence
• Risk Factors
• Chronically ill patients and what to assess for 
• Psychosocial / Psychological assessments
• The Columbia-Suicide Severity Rating Scale (C-SSRS) and screening in primary care
• Highlighting a patient safety plan and provide a template

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