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

Dr Rachel Gibbons, Dr Mayura Deshpande, Dr Elizabeth Venables, Dr Mary Ryan, Debbie Frances

75 minutes


June 2022

Congress webinar


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


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