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National Patient Safety Agency

NPSA works to improve mental health patient safety investigations

13 March 2008

 The National Patient Safety Agency (NPSA) today launched guidance aimed at improving and standardising the approach to independent investigations into serious patient safety incidents in mental health services.


Independent investigation of serious patient safety incidents in mental health services good practice guidance describes the three main stages of the independent investigation process in detail, examining the initial service management review, internal NHS mental health trust investigations and Strategic Health Authority independent investigations. The document also looks at how NHS organisations can support the victims of serious incidents, families, carers and perpetrators, how to support staff and other affected mental health users.


The initial service management review is an internal trust review within 72 hours of the incident being known about in order to identify any necessary urgent action. The more in-depth internal NHS mental health trust investigation uses root cause analysis or a similar process to establish a chronology and identify underlying causes and any further action that needs to be taken and is usually completed within 90 days of the incident. SHA independent Investigations are commissioned and conducted independently of the providers of care.


The NPSA's Chief Executive Martin Fletcher said “We recognise it is essential that serious incidents occurring in all care settings are investigated locally to ensure that, where possible, urgent action is undertaken to protect patients and staff and that appropriate learning is shared nationally. Our guidance for the mental health sector represents a framework of best practice to enable the root causes of incidents to be identified and communicated in an open and honest manner to all concerned. It is designed to guide staff through the process in a consistent manner across the NHS.”

Health Minister Ivan Lewis said: "The vast majority of mental health patients receive safe and effective care, however tragedies do occur. We must ensure that we are doing everything to learn from them and to improve services accordingly.


Today's guidance will help ensure that mental health investigations across the NHS are carried out in a consistent and coordinated way and involve families and relatives appropriately."


Jayne Zito OBE, Patron of The Zito Trust said:  “Good practice guidance is needed to help those involved in independent investigations communicate more effectively with victims and families.  The Zito Trust has been concerned by the failure of a small but significant number of agencies involved in these cases to meet the needs of those who have been bereaved by tragedy.  This guidance will give NHS organisations the confidence to approach families openly and to engage them meaningfully in what is a complex and difficult process for everyone involved.”


Ben Thomas, Head of Mental Health and Learning Disabilities at the NPSA said: “The Independent investigation of serious patient safety incidents in mental health services good practice guidance is a practical resource, in particular for those who are faced with responding for the first time to such an incident. Dealing with the aftermath of a serious incident can be a daunting task for all involved and the guidance aims to help conducting independent investigations in a timely, co-ordinated and robust fashion as systematic as possible.”


The document has been drawn up in consultation with the Department of Health, Healthcare Commission, Strategic Health Authorities, mental health trusts and The Zito Trust.




Notes to editors

  1. For further information please contact Senior Communications Manager, Nick Rigg on 020 7927 9362.
  2. The National Patient Safety Agency (NPSA) helps the NHS learn from its mistakes so that it can improve patient safety. It does this by collecting reports on errors and other things that go wrong in healthcare so that it can recognise national trends and introduce practical ways of preventing problems. It does not investigate individual cases or complaints, but it does listen to public concerns and uses what is said to improve safety.