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“Around 2.5 million people are in contact with secondary mental health, learning disabilities and autism services each year and the deathsof many patients will be unconnected to the care they received. But it is crucial that ways of improving services are learned from patients’deaths.“ Dr Adrian James, Registrar, The Royal College of Psychiatrists, November 2018“Learning from deaths is an essential part of quality improvement work for organisations.”The Mortality Review Tool Guidance, Royal College of Psychiatrists, November 2018“The NQB guidance requires that all inpatient, outpatient and community patient deaths of people with severe mental illness (SMI) shouldbe subject to case record review.” NHS Improvement“Through our well led inspections we have seen trusts that have made positive changes to ensure that learning from deaths is given thepriority it deserves… However, the speed of progress varies, and our review indicates that problems with the culture of some organisationsis preventing sufficient progress… We will continue to assess the progress trusts are making through our inspection and monitoring andto hold trusts to account when we find improvements are required… Alongside this, there needs to be continued support from the centre,including support for behaviours that encourage more openness and learning across the NHS, clearer guidance for community and mentalhealth trusts, and a more focused consideration of the progress being made on reviews and investigations of deaths of people with mentalhealth problems or a learning disability which was highlighted as a priority in our original thematic review.”Professor Ted Baker, CQC’s Chief Inspector of Hospitals March 2019This conference focuses on Improving the Quality & Learning from Investigation of Deaths & Serious Incidents in Mental Health Services.Through national updates, practical case studies and extended sessions, the conference will provide a step by step guide to high qualityinvestigation and learning from deaths of people who received care from their mental health service. The conference will also look at effectiveimplementation of the November 2018 National Mortality Care Review Tool developed by the Royal College of Psychiatrists. “The Care ReviewTool is suitable for supporting mortality reviews for patients who were under the care of mental health Trusts and it can be adapted for use byjoint mental health and community Trusts… The tool allows explicit judgements around a patient’s care to be made, with a score given for eachphase of care. The aim of this tool is to make it possible for Trusts to screen all deaths of patients in contact with mental health services and,through thematic analysis of a number of completed forms, to: 1. Determine areas of good care that can be recognised and further developed2. Recognise areas where care can be improved” Royal College of Psychiatrists November 2018This conference will enable you to:• Network with colleagues who are working to improve serious incident investigation, mortality review and learning from deaths in MentalHealth services• Learn from outstanding practice in implementing the Royal College of Psychiatrists Mortality Care Review Tool• Reflect on national developments and learning• Improve the way you involve and engage families and carers in the investigation process• Develop your skills in incident investigation and mortality review• Understand how you can improve serious incident investigation and understand the recent changes to the NHS Improvement SeriousIncident Framework• Identify key strategies for undertaking a self assessment, and continuous review of deaths and investigation practice in your organisation• Understand how human factors, and simulation can help improve learning from serious incident investigation• Ensure you are up to date with the role of the coroner• Self assess and reflect on your own practice