MC4 Delusions of perfection - the problem with serious incident inquiries: What can we do to change the investigation process and really learn from tragic events?

Date: Monday 20 June
Time: 15.20 - 16.35
Stream: Quality improvement

There is currently a high demand from many families, clinicians and managers to review the current serious investigation process that fails almost everyone. The current serious incident investigation process in many mental health organisations, inhibits true learning from tragic events. For many it can be experienced as persecutory and re-traumatising. If our current system is inadequate and doesn’t work – what would? What is the purpose of these investigations – is it to understand the care pathway, to examine the quality of care provided in that instance, to explore opportunities for improvement to services, or to attribute blame? Can one process ever hope to achieve all these things? And in practice, do serious incident investigations ever result in improvement in services or quality of care? This workshop aims to address the current problems and to start to develop a way forward.

Chair: Dr Rachel Gibbons, Chair of the Patient Safety Group, Royal College of Psychiatrists

Is there a root cause? Even if there is - can we ever identify it?

Dr Mayura Deshpande, Chair of the Ethics Committee, Royal College of Psychiatrists

The emotional toll of the investigation: personal experience

Dr Elizabeth Venables, East London Foundation Trust

Moving from blaming to learning - how the perspectives and experiences of patients, friends and families can contribute to learning from, and prevention of, serious incidents

Dr Mary Ryan, Mental Health Safety Improvement Programme, Royal College of Psychiatrists

Carers perspective of the problem with Serious Incident Inquiries

Debbie Francis, Expert by experience


  • Dr Rachel Gibbons

    Chair of the working group on the effect of suicide and homicide on clinicians at the Royal College of Psychiatrists

  • Dr Mary Ryan

    Mental Health Safety Improvement Programme, Royal College of Psychiatrists

Please email or call 020 8618 4120 with any enquiries.