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
Elena baker-glenn started the conference with an overview of the Care Review Tool, covering reviews in Mental Health Trusts. Elena talked about how this process has changed since in 2016 and in 2019 to reflect various scenarios that should prompt further investigation.
She openly discussed ways the investigation process is being improved, including a deep dive into the experience of using the Serious Incident Review Accreditation Network, and how it is being learned.
After her talk, Elena took several questions directly from delegates which allowed for a highly engaging and interactive beginning to the day.
Looking at deaths & serious incidents from a user/family perspective
Dorit Braun
Retired Charity Chief Exec with personal experience of avoidable harm in the NHS and of working to try to support the NHS to learn from that harm
• 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
Dorit Braun generously gave an open and transparent talk about her personal experience as a family member of someone who tragically passed away due to mental illness.
Her story delivered an insightful perspective of the difficulties that family members face in a death investigation, raising questions for why things were done a certain way and how they could be improved.
Dorit’s talk concluded with a questions and answer section from delegates, including the question ‘what about family members who wish to not be involved’. This session revealed the different attitudes and beliefs people encounter in tragic circumstances.