Serious incidents can occur that put patients, carers, family members,friends, staff, members of the public, or the provider organisation at risk or cause them harm. Learning from serious incidents is essential, and a culture of openness should be present in every organisation.
However, despite healthcare providers being under greater pressure to investigate and learn from serious incidents, there a lack of evidence about how we can learn from such incidents.
In addition, the threshold for what is classed as a serious incident varies between organisations, which can make comparing methods of investigation and learning challenging.
Moreover, the quality of the investigations varies and there is also variation in the way that patients and families or carers are engaged in the process. We're committed to addressing standards for investigations.
Through our Invited Review Service, the College has identified a set of guiding principles.
We've created a document which sets out the principles of good practice for investigations conducted by mental health and intellectual disability provider organisations, following serious incidents in both the NHS and independent sectors across the whole of the UK.
The principles were developed following a literature review of existing frameworks and guidance, followed by consultation with experienced investigators and other stakeholders, including service users and carers.