Serious incident investigations and suicide
Research type
Research Study
Full title
Examine the quality and rigour of the Serious Incident Investigation (SII) process following suicide under community mental health services to inform organisational learning regarding risk reduction.
IRAS ID
298451
Contact name
Helen Catherine Haylor
Contact email
Sponsor organisation
Bradford District Care NHS Foundation Trust
Duration of Study in the UK
1 years, 0 months, 1 days
Research summary
Serious incident management and organisational learning are NHS patient safety priorities. Although suicide prevention is a public health imperative, there were 5,691 suicides in the UK in 2019.
One third of those who took their lives had recent contact with MH services, with the majority not judged at risk in their last contact. Evidence suggests deficiencies in risk assessment, guidance and staff training. There are concerns that lessons are not being learned from suicide incident investigations, disguising improvements to risk management and patient safety.Various studies have already focussed on suicide risk-prediction/management within mental health services, while others view systems models of analysing incident causation as potentially yielding alternatives to root cause analysis.
This study is co-designed with carers. We will explore current approaches to Serious Incident Investigation (SSI) specific to community-based suicides, including risk assessment - as part of a care process, and how these approaches align to good practice, and carers’ perspectives on SSIs. Following a literature review, we will examine the views of clinicians, investigators, senior managers, and carers, to elucidate barriers and enablers to good practice. Data collection will be in a mental health and community NHS Trust in two phases:
(1) Two separate focus groups with carers, and MH clinicians, who have experienced suicide serious incident investigations
(2) we will use data gathered from (1) to inform semi-structured interviews with SI investigators, and their senior managers to explore common themes in more depth. A pragmatic approach to data analysis will be employed.
The findings will improve the SII process, and any subsequent learning under the broader aim of improving patient safety. Study duration is 12 months. This is sensitive research for all involved and will adhere to ethical principles throughout. The study is funded by the West Yorkshire Patient Safety Translational Research Centre (NIHR).REC name
North West - Greater Manchester East Research Ethics Committee
REC reference
21/NW/0189
Date of REC Opinion
11 Aug 2021
REC opinion
Further Information Favourable Opinion