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This national conference looks at the practicalities of Serious Incident Investigation and Learning from Deaths in Mental Health Services and implementation of the New Patient Safety Incident Response Framework (PSIRF previously known as the Serious Incident Framework). The Patient Safety Incident Response Framework (PSIRF) was published on 16th August 2022 and replaces the Serious incident Framework.
“Early adopters of the Patient Safety Incident Response Framework (PSIRF) are reporting improved safety cultures, identification of more effective risk reduction strategies and early signs of harm reduction, due to their revised approach.”
The conference is particularly timely considering the current Essex Mental Health Independent Inquiry and the recent investigation onto concerns regarding CAMHS provision at Tees Esk and Wear Valleys NHS Trust both of which have 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.
We welcome the publication of NHS England’s new Patient Safety Incident Response Framework (PSIRF) and the focus it places on effective learning and compassionate, meaningful engagement with those affected when incidents occur. Through our monitoring and inspection we have seen how the existence of a strong organisational safety culture, where the views of staff and patients are listened to and acted on, and learning is prioritised is essential to good practice in responding when things go wrong.
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
