Learning from serious incidents in mental health services

Chris Brougham Verita Consultancy Ltd

Chris Brougham

Published 28 August 2015 More about Chris

Serious incidents

Serious incidents in mental health services and learning from these mistakes is not a new concept in the NHS or in mental health. National guidance published in 2008, The Seven steps to patient safety in mental health,  provides advice on learning and sharing safety lessons and implementing solutions to prevent harm (steps 6 and 7 respectively).  Five years later, Professor Don Berwick in his report on patient safety called for the NHS to become a “system devoted to continual learning and improvement of patient care, top to bottom and end to end”.

Despite this, we constantly see evidence at Verita that many mental health trusts are struggling to put sustainable solutions in place after a serious incident.  Some don’t have systems in place to promote learning or monitor whether any changes made have had a positive impact.

Verita has a worked with mental health trusts on hundreds of serious incidents and we have identified a number of factors that stop lessons being learnt:

  • the initial investigation fails to identify correctly the issues that contributed to the incident
  • recommendations are not always SMART (specific, measurable, and achievable, results orientated or include a timescale) making an action plan difficult if not impossible to achieve
  • the action plan does not reflect the difficulty and complexity of putting the recommendations in place
  • not enough effort is put into winning hearts and mind so that improvements are not accepted by everybody who needed to change practice
  • improvements are made but over time people slipped back to their old ways of working
  • the link between preventing serious incidents and long-term financial gain is not made.

Verita has developed a diagnostic toolkit to help trusts see where their strengths and weaknesses lie which provides a good starting point for putting sustainable improvements in place following serious incidents.

For more information, contact me on 0113 418 0165  or [email protected].

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