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News and updates at today's Investigation of Deaths & Serious Incidents in Mental Health Services conference

Following the chairs introduction, Mary-Ann Bruce from Mazars LLP delivers an opening address on 'Improving the Quality of investigations of deaths in mental health services Learning from the Mazars Report a year on', covering:

• key learning from the MAZARS report into Southern Health

• how can services secure the right level of review, enquiry or investigation following a death

• common themes from the review

Mary-Ann comments:

"Investigations and greater curiosity 
How many deaths?
How old are they? 
'Be more curious, not do more investigations'
Organisations need to work together
'Mental health patients die earlier- fact need to look at reasons and who is responsible for investigating them'
Lots of data but does anyone use it?
We need to try to improve the understanding of deaths
'Start somewhere and ask a question'
When do you decided to investigate? 
Limited logic
Is it a serious investigation? 
'Deaths are not incidents'
Can looked across the 12 sites and 1 came up to standards 
Templates are driving how the reports are made up 
Governance is comment on framework need to bring everyone experience on new framework 
Trusts are asking questions- everyone must ask these 
'Different processes to different services'
Families need to be involved if they wish
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    Nicki Morrison    RE: Docs.net    12:26 PM    303 KB    tions with an action plan will be a national priority 
We need to get to a shared approach"

Sue Bos Independent specialist in investigation Patient Safety Science, continues with an extended session on 'Effective investigation: tools, principles and practice', including:

• which deaths to report and investigate
• a step by step guide to undertaking an effective investigation of a death in a mental health or learning disabilities setting
• systems for information gathering
• interviewing staff involved in serious incidents - techniques and tips
• writing the investigation report - techniques and tips.

Sue comments:

"Objective of rca investigation and was shocked on how people are and sharing 
Key to getting started, don't judge too quickly 
Language on reporting is key so everyone can follow and understand 
Questions... who and what do we need to get started in an investigation 
Site visits a key and photos need to be taken
Asking the family... what would have made a difference? 
Root cause analysis- ask family what went wrong
'Recording provides evidence'
Identifying contributory factors.... we no longer stop once we have identified the problems 
'Better to demonstrate that ignoring if your unsure' 
Big question... poor care?? Difficult to find in root cause in mental health 
People interviewing staff involved in serious incidents- primarily thinking about family secondly the staff 
Investigating reporting templates should push to get involvement with the family "

Presentation abstact:

Safety is not rocket science…..but it is a science!

Root Cause Analysis (RCA) makes a unique contribution to patient safety. It is based on the examination of human error and a thorough methodology for analysing 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.

Information provided is up to date and fully aligned with NHS England’s Serious Incident Framework.

Sue's biography:

Sue has worked in the NHS throughout her career, holding a wide range of managerial positions in acute, community and mental health trusts.

During 12 years as Director of Specialist Mental Health Services in Leicestershire she established and developed the role of clinical director for each of six specialist services, encouraging clinicians to take full managerial responsibility for their services, including all aspects of clinical governance and patient safety. She took a trust-wide lead on issues relating to incident reporting and investigation and undertook several major investigations into serious incidents, including homicides.

Since leaving the trust Sue has delivered many training courses in root cause analysis and Being open/Duty of Candour for the NPSA, NHS England and currently for Patient Safety Science Not For Profit Ltd (PSS). She has been an associate investigator for the Health Service Commissioner and a non-executive director of Compass, an independent provider of drug treatment services. Sue has also undertaken several major independent, complex investigations within the NHS.

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Electronic Prescribing in Mental Health
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Improving the Physical Health of Adults with Severe Mental Illness
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Achieving Better Access for Mental Health Crisis Care
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Medically Unexplained Symptoms /Somatic Symptom Disorder National Summit 2017
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Service User Experience in Mental Health
Friday 12 May 2017 
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10 February 2017

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