Safety
This section contains all elements to do with safety, systems, processes, guidance and examples of how services have developed safer systems and the tools available to do so.
 | Title: Peter Hasler presentation v2 Stone Published: 2007 Summary: Powerpoint document on The Michael Stone Inquiry - Peter Hasler, Director of Nursing & Modernisation, Kent & Medway NHS & Social Care Partnership Trust. |
 | Title: SUI's presentation Published: December 2007 Summary: Powerpoint document on Local Investigations into serious adverse events in mental health services - Colin Phillips and Sian Rees, Department of Health. |
 | Title: The Kerr Haslam Inquiry (Third version) - Ros Alstead Published: November 2007 Summary: Powerpoint document on the Kerr/ Haslam inquiry - What have we learnt and what can we do better? - Ros Alstead, Director of Nursing, BSMHT & Panel member of Kerr/Haslam Inquiry 2002-05. |
 | Title: NPSA PROJECT report Published: 2006 Summary: NPSA Project - Involving patients in their safety. The focus of the Merley Ward project was the involvement of patients in improving actual and perceived safety on the ward. |
 | Title: NPSA Safety in Mental Health Published: July 2006 Summary: With safety in mind: mental health services and patient safety. Patient Safety Observatory Report 2. |
 | Title: Help is at hand - Guide for people bereaved by suicide Published: 2006 Summary: A resource for people bereaved by suicide and other sudden, traumatic death. This guide is aims firstly to help people who are unexpectedly bereaved in this way. It also provides information for healthcare and other professionals who come into contact with bereaved people, to assist them in providing help and to suggest how they themselves may find support if they need it. |
 | Title: SUI-S Health records audit tool Published: September 2006 Summary: Please complete the relevant sections of this tool depending on the type of service being audited. Sections include: Demographic information, General information, Assessment and care planning, Carer information, Discharge planning, Prescription kardex and ECT. |
 | Title: MERT poster for NAPICU Published: 2006 Summary: Introducing a medical emergency response team (MERT) into a mental health in-patient facility. MERT in Mental Health Hospitals ensures existing skills of staff provide better assessment and monitoring of a patients physical safety during medical emergencies, restraint and seclusion incidents. |
 | Title: MERT Final Published Article Published: 2006 Summary: Twenty four hour medical emergency response teams in a mental health in-patient facility – New approaches for safer restraint. This article provides background and a syllabus for training for staff to be able to meet the physical assessment skills and interventions required by recent UK national guidance. |
 | Title: Defining a good MH service Published: November 2005 Summary: This discussion paper presents initial calculations on the specification and workforce requirements for a good mental health service: one that would be able to implement in full the 1999 National Service Framework for Mental Health and subsequent government guidance. |
 | Title: Gemma Hearn inquiry Published: January 2005 Summary: Report into the care and treatment of Gemma Hearn. |
 | Title: Dale Pick inquiry Published: January 2005 Summary: Report of the Independent Inquiry into the Care and Treatment of Dale Pick. Title: Joe Janes inquiry Published: 2004 Summary: The Report of the Inquiry into the Care and Treatment of Joe Janes. |
 | Title: Anonymised report - Audit Commission Published: November 2004 Summary: There is no nationally accepted model for staffing acute inpatient units. The audit commission examined a number of Trusts activity and resourcing and serivce user portfolios across adult rehabilitation, acute admission and low secure inpatient environments. This report highlights the need for better profiling of nursing staff against service user need. |
 | Title: Chandran Sukumaran inquiry Published: May 2004 Summary: Independent Inquiry established to examine all the circumstances surrounding the care and treatment of Chandran Sukumaran. |
 | Title: Safe and Therapeutic Management of Aggression Published: February 2004 Summary: Mental Health Policy Implementation Guide. Developing Positive Practice to Support the Safe and Therapeutic Management of Aggression and Violence in Mental Health In-patient Settings. |
 | Title: Positive practice managing violence Published: July 2004 Summary: Mental Health Policy Implementation Guide – Developing positive practice to support the safe and therapeutic management of aggression and violence in mental health inpatient settings. This guidance, and the standards it contains, have been formulated to support services in reviewing existing policies, education, training and practice on the management of aggression and violence training and personal safety. |
 | Title: Daksha Emson inquiry Published: October 2003 Summary: Inquiry set up to investigate the causes of the deaths of Dr Daksha Emson and her daughter. |
 | Title: Mark Harrington inquiry Published: November 2003 Summary: Independent Inquiry to consider the care and treatment Mark Harrington received from the statutory agencies. |
 | Title: David Bennett inquiry Published: December 2003 Summary: Inquiry set up as a result of the death of Mr David Bennett at The Norvic Clinic on 30 October 1998. |
| | Title: Mrs K inquiry Published: 2003 Summary: Mental Welfare Commission for Scotland. Inquiry Summary – Mrs K. Title: Matthew Martin inquiry Published: July 2003 Summary: Report of the Independent Inquiry Into the Care and Treatment of Matthew Martin. Title: Nottingham Patient A inquiry Published: November 2005 Summary: Report of the Independent Inquiry Into the Care and Treatment of Patient A. |
 | Title: DD - Barrier analysis Published: September 2003 Summary: Dual diagnosis. It is important to recognise when and why control measures have failed, in order to prevent patient safety incidents. Barrier analysis helps the review team to establish which barriers (defence or controls) were in place and whether they worked or not. It can also be used to establish the type of barriers that should have been in place to prevent the incident, or could be installed to increase the system safety. |
 | Title: DD - Case Study: Primary care Published: September 2003 Summary: Delayed diagnosis. This is one of a resource of case studies designed to illustrate the application of root cause analysis tools and techniques in different healthcare settings. The cases will include patient safety incidents involving mental health care services, ambulance services and other care groups and services. Title: DD - Case Study: Wrong site surgery Published: September 2003 Summary: This patient safety incident has been chosen to explain a variety of Root Cause Analysis tools and techniques because of the nature of the problem and the potential severity of wrong site surgery for all concerned. |
| Title: DD - Guidance: Multi-professional reviews Published: September 2003 Summary: Multi-professional team review. This should be regarded as a positive process providing an opportunity for the team involved in the events that subsequently led to a patient safety incident to meet, review chronology of events and causal factors and subsequently generate recommendations. Title: DD - Guidance: Contributory factors classification system Published: September 2003 Summary: A key stage of Root Cause Analysis involves identifying those issues which may have had an influence or may have directly caused a patient safety incident. This document describes a framework for classifying such factors. Title: DD - Guidance: Data collection Published: September 2003 Summary: As part of the investigation process it is important that all documentation relating to the patient safety incident is recorded and stored in a logical fashion. This will assist the investigation team in establishing the chronology of events surrounding the incident. Title: DD - Guidance: Site visits Published: September 2003 Summary: As part of the information gathering process it can be helpful for the Root Cause Analysis team to visit the site where the patient safety incident occurred. |
| Title: DD - Tools: Brainwriting Published: September 2003 Summary: The investigation team may need to generate ideas about the patient safety incident, or a particular aspect of the incident, at some point during their work.Where anonymity may be important for the group generating ideas, or where complex issues are involved, Brainwriting may be a useful tool to use. This document discusses its nature and application. Title: DD - Tools: Brainstorming Published: September 2003 Summary: The investigation team may need to generate ideas about the patient safety incident, or a particular aspect of the incident, at some point during their work. Where it is important or useful to involve several people in generating ideas, Brainstorming can be a useful tool to help. There are different forms of Brainstorming and this document describes their nature and application. Title: DD - Tools: Narrative chronology Published: September 2003 Summary: When the investigation team conducts a detailed investigation into the events contributing to a patient safety incident, a vast array of information can be collected - often from a number of diverse sources. This information will be used to help the investigator, or investigation team in identifying what happened, how it happened and why it happened and to complete an investigation report. |
 | Title: Standards Published: April 2002 Summary: National Minimum Standards for General Adult Services in Psychiatric Intensive Care Units (PICU) and Low Secure Environments. In May 2001 the PICU Policy Research and Development Group based at NELMHT were specially commissioned by the Department of Health to produce National PICU Standards. The Group initiated a PICU and Low Secure Practice Development Network. This Network, which consisted of a multidisciplinary group of professionals and user representatives from around the UK, met for 9 consensus workshops between May 2001 and January 2002. The aim of the workshops was to develop standards for psychiatric intensive care and low secure environments. |
 | Title: DN inquiry Published: September 2002 Summary: Independent Inquiry into the Care and Treatment of DN. |
 | Title: SH 2002 Published: July 2002 Summary: Report of an Independent Inquiry Into the Care and Treatment of SH. |
 | Title: Mr J inquiry Published: September 2002 Summary: Report of the Inquiry Into the Care and Treatment of Mr J. |
 | Title: Building a Safer NHS Published: April 2001 Summary: Building A Safer NHS For Patients sets out the Government’s plans for promoting patient safety following the publication of the report An Organisation with a Memory and the commitment to implement it in the NHS Plan. |
 | Title: Longman, Huntingford and Moffatt inquiry Published: July 2001 Summary: Report of an Independent Inquiry into the Care and Treatment of Mark Longman, Paul Huntingford and Christopher Moffatt. |
 | Title: Organisation with a Memory Published: 2000 Summary: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. |
 | Title: NPSA Safety Acute Summary: The first year: Sue Brace, Project Manager, National Patient Safety Agency. Covering: Site visits, Key observations, Prioritization, Major themes, Development of a meaningful day, Physical environment, Service user involvement, Pilot sites, Physical environment, Visible presence of staff, What happens next. |
| Title: NAPICU Standards http://www.napicu.org.uk/napicustandards.htm Summary: The National standards for In patient PICU and Low Secure Services were launched at the Department of Health by Jacqui Smith MP, Minister for Health on Tuesday, April 30th 2002. The work undertaken by the Practice Development Network facilitated by NAPICU and NELMET played an important part in the development of the standards for Pychiatric Intensive Care. The standards are minimum standards which can be used to benchmark the quality of services. | |
| Title: Management of violence and aggression http://www.napicu.org.uk/napicupmva.htm Summary: In February 2005, NICE published guidance on the shorterm management of disturbed behaviour. A national confernce jointly hosted by the University of Central Lancashire and NIMHEE on the subject was held in March 2005 where the guidance was officially launched. | |
 | Title: Open door policy draft 10 Summary: Review of open door policy in acute in-patient wards. The purpose of this paper is to consider contemporary philosophy, policy and practice relating to the locking of exit doors, and to stimulate debate, review existing attitudes, challenge current approaches and improve standards of sensitive, yet safe care. |
 | Title: Working with Risk Summary: Working with risk: Steve Morgan - Practice Based Evidence. Current situation, Detailed review, Guidelines for positive risk taking. A checklist for patients who are at risk to themsleves or others with sections for Known history, Initial assessment, Risk management plan, Confidentiality, Risk indicator checklist etc. |
 | Title: Risk assessment and CPA Summary: National Risk Management Programme (London Development Centre) and CPA review: Anouncement. |
 | Title: Controlled Egress- Final report NIMHE Summary: Report into controlled egress pilots. This report is designed to help the trust management team consider the proposed changes to the practice of all the adult mental health units being generally open so that patients are able to leave without the intervention and sometime knowledge of the staff. |
 | Title: Review of safety in ECT Summary: Systematic review of the efficacy and safety of electroconvulsive therapy UK ECT Review Group. Commissioned and funded by the UK Secretary of State for Health. This report describes a systematic review and meta-analysis of the efficacy and safety of ECT in depressive disorders, mania and schizophrenia. |
 | Title: Independent Investigations Summary: Independent investigation of adverse events in mental health services. |
 | Title: Incident audit Summary: Acute Care Collaborative: Incident Audit - King's London Development Centre For Mental Health. |
 | Title: Bullying - Jane Ireland Summary: Presentation on bullying, steps to understanding, management of core competencies of staff, supervision, communication, environmental and individual action plans. |
