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Implementing the Patient Safety Incident Response Framework (PSIRF) in Mental Health Settings - Investigation of Deaths & Serious Incidents

This national conference looks at the practicalities of Patient Safety Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework.  

Putting people at the heart of patient safety investigation

• 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

Dorit Braun

Retired Charity Chief Exec with personal experience of a coroner’s inquest

Dorit retired in 2019, having worked as a Charity Chief Executive and in a variety of senior management and governance roles in the social care and family support sectors.  Following a very traumatic family bereavement Dorit is active in trying to improve mental health care and the ways NHS staff and organisations learn from deaths. She is on the UCH Learning from Deaths research programme steering group, and in this capacity has contributed to manuscripts for publication; she is on the Action Against Medical Accidents (AvMa) beneficiaries participation group; is a member of Making Families Count (MFC); provides training to NHS trusts and other professionals by speaking about her family's experiences and has blogged about aspects of these experiences.    

Dorit is coordinating a new project with MFC:  Life Beyond the Cubicle aims to reduce deaths of people during acute mental health crises, by enabling professionals to listen, support and assist families to help keep loved ones safe.

Dorit obtained her PhD in 1980 from the University of Manchester; her research was on the political economy of the pharmaceutical industry in Colombia. She has a Masters from Warwick University on Social Research in Health Care; her dissertation was on feminist research methodology.  She was awarded an OBE in 2000 for services to parenting.  Dorit is also an artist, exhibiting from time to time. 


Using the National Mortality Review Tool and Improving Standards for Safety Incident Responses through Accreditation

• 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 Safety Incident Response Accreditation Network to improve the investigation process and learning


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Dr Elena Baker-Glenn

Clinical Director, East London NHS Foundation Trust, Chair of Safety Incident Response Accreditation Network, Royal College of Psychiatrists

Elena is a consultant in liaison and perinatal psychiatry and is currently working as a clinical director for crisis pathway and perinatal services across Bedfordshire and Luton, East London NHS Foundation Trust. She completed a national medical director’s clinical fellowship programme in 2016/17 where she was based with the Royal College of Psychiatrists and she led on the work to develop the care review tool and helped with the establishment of the Serious Incident Accreditation Network. She continues to chair the Safety Incident Response Accreditation Network at the Royal College of Psychiatrist and has a strong interest in both improving patient safety and in quality improvement.

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