This document describes ways in which the process of independent investigations of serious patient safety incidents in mental health settings can be improved. It supports guidance issued by the Department of Health in June 2005. The guidance aims to help ensure a consistent approach to investigations across the health service and to raise standards.
It is relevant to strategic health authorities, primary care trusts, local authorities and all mental health trusts, including foundation trusts.
The three stages of the independent investigation process are described in detail in the document. These are: initial service management review, internal NHS mental health trust investigation, and SHA independent investigation.
The document also covers:
- supporting victims of serious incidents, families, carers and perpetrators, staff; and other mental health service users;
- communication with the media;
- the Human Rights Act 1998;
- checklists for trust initial review and investigation;
- root cause analysis;
- SHA checklist for independent investigation;
- the Salmon Principles; and
- correspondence checklists.