Learning from serious incidents, near misses, and abuse is a core aspect of contemporary practice in psychiatry. During our careers, all psychiatrists will participate in such reviews. Psychiatrists regularly receive all manner of safety alerts and recommendations from a wide variety of sources and investigating authorities, ranging from internal reviews, through inspections and inquests, all the way to national safety investigations and public inquiries. Alongside the clinical demands of modern practice, how can we find the time and attention to keep on top of so many reports and recommendations?
The Healthcare Services Safety Investigation Branch has identified this as a priority topic of concern, and in 2024 published a report, “Recommendations but no action”, which proposes improvements to the current approach. In psychiatry, inquiries into abuse have been conducted since at least the 1960s and several are currently ongoing. Although progress has been made in protecting patients, some contemporary recommendations duplicate those of historic reports, suggesting that further action and meaningful change is urgently required.
This session presents research, lived experience, policy, and clinical practice. We present the findings of a thematic analysis of inquiries into six psychiatric institutions from the 1960s to the present day. This research describes a thematic structure at which relevant processes operate comprising three levels – proximal, organisational, and system - with a cross-cutting theme of the manner in which concerns are responded to. Arising from this research, we propose a novel, generalisable framework that can be used to structure learning, preventative measures and future investigations. We present an overview of the national picture and current approaches to safety investigations, propose measures to improve effectiveness, and offer tips for the busy clinician to navigate their way through it all.
Learning objectives
In this session you will learn about:
- The findings of a thematic analysis of inquiry reports
- Considerations for the care and support of both patients and professionals during a review or inquiry
- A conceptual framework for implementing safety recommendations at organisational, team, and individual practice levels
- Current priority safety recommendations for clinical practice in mental health.
Speakers
Chair: Dr Alex Thomson, Central and North West London NHS Foundation Trust, London
Dr Rachael Elliott, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
Dr Emma McAllister
Dr Alex Thomson, Central and North West London NHS Foundation Trust, London
Availability
This webinar is part of the Congress webinar 2025 package. If you attended all four days of Congress, you will have access to these as part of your Congress package. Otherwise the Congress webinar 2025 package can be purchased below.
