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Investigation of Deaths & Serious Incidents in Mental Health Services- Towards the Patient Safety Investigation Framework (PSIRF)

Thursday 18 Aug 2022


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Find out more about virtual attendance

This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework). NHS Improvement is working with these early adopters to test implementation, and analysis of this will inform the final version with the revised framework due in June 2022. Local systems and organisations outside of the early adopter areas are free to use the already published version of the PSIRF to start to plan and prepare for PSIRF’s full introduction.

The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement, and updates from PSIRF early adopter sites in mental health. The conference will also examine how the new framework will fit with the Royal College of Psychiatrists Care Review Tool for mortality review.

The conference is particularly timely considering the current Essex Mental Health Independent Inquiry which has National Implications: 
“The Inquiry was established to examine deaths which have taken place in mental health inpatient settings within NHS Trusts in Essex. The Inquiry will look at the key factors which led to the deaths of individual patients, as well as cultural and governance issues which may have inhibited the Trusts’ ability to learn and take action following breaches of safety. The Inquiry will also assess the quality of previous investigations and reviews. The Inquiry aims to make actionable recommendations to improve health care not only within Essex, but across the NHS and the wider system.”  Essex Mental Health Inquiry 2022

“To support the NHS to further improve patient safety, we are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF), outlining how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.”

NHS England

“PSIRF supports a systematic, compassionate, and proficient response to patient safety incidents; anchored in the principles of openness, fair accountability, learning and continuous improvement. The approach aims to refocus systems, processes and behaviours on delivering a sustained reduction in risk. It is recognised that national implementation, with fidelity to the principles and thinking behind PSIRF requires information, education and support. The evaluation found enthusiasm for the approach among the vast majority of those involved in the Early Adopter organisations. Interviewees anticipated benefits compared with the previous framework. The value of the pilot has been to provide an opportunity to identify some of the key challenges which will require attention for successful implementation of the wider roll-out.”

PSIRF Pilot Evaluation - December 2021 v2 edit Crisp QI Report, NHS England

This conference will enable you to:

  • Network with colleagues who are working to improve the investigation of serious incidents and deaths in mental health services
  • Ensure your approach to Serious Incident Investigation is in line with the Patient Safety Incident Response Framework (PSIRF)
  • Learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool
  • Reflect on the lived experience of a bereaved relative 
  • Improve the way you involve and engage families and carers in the investigation process
  • Develop your skills in incident investigation and mortality review
  • Understand how you can improve serious incident investigation and learn from Mental Health early adopters of the New Patient Safety Incident Response Framework 
  • Identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation
  • Understand how human factors can help improve learning from serious incident investigation
  • Ensure you are up to date with the role of the coroner
  • Understand how you can better support staff when a serious incident occurs 
  • Self assess and reflect on your own practice
  • Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes

Chair and Speakers Include:

Dr Panchu Xavier

Consultant Forensic Psychiatrist and College Tutor, Chair – Ethical Advisory Group, Deputy Medical Director – Quality and Patient Safety, Director of Patient Safety, Mersey Care NHS Foundation Trust

Dr Elena Baker-Glenn

Liaison Psychiatrist, Northamptonshire Healthcare NHS Foundation Trust and Chair of SIRAN Accreditation Panel, Royal College of Psychiatrists

Mike O'Connell

Legal Services Practitioner and Interim Senior Inquests Manager
Calderdale and Huddersfield NHS Foundation Trust

Geraldine Strathdee

Independent Inquiry into mental health inpatient deaths in Essex

Exhibition & Sponsorship Packages

This conference offers a valuable opportunity for industry suppliers to personally meet with their target audience where they will have time to talk and demonstrate the benefits of their products. High quality specialist audiences make having a presence at our events a highly targeted and cost effective marketing channel.

Why Exhibit?

Having a presence at this event will give you the opportunity to:

  • Demonstrate your product, system or service
  • Network and engage with your key audience  
  • Generate new business leads
  • Gain exposure for your brand and raise the profile of your organisation
  • Understand the current needs of your audience and challenges they’re facing
  • Update your knowledge of national policy and local developments  


Contact Carolyn Goodbody for exhibition and sponsorship prices, or to discuss a tailored package to suit your needs and budget.

Fee Options

NHS, Schools & Public Sector



Voluntary sector & charities



Commercial organisations



Virtual Training



(Prices in brackets include VAT)


Additional delegate discount:

A discount of 15% will be applied to fees for any extra delegates.

Online discount:

A discount of 10% will be applied if you pay using the website.

Also of Interest

Supporting Organisations

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