Root Cause Analysis and Mental Health Incidents
| Published date | 01 September 2004 |
| Pages | 17-20 |
| Date | 01 September 2004 |
| DOI | https://doi.org/10.1108/13619322200400026 |
| Author | Suzette Woodward,Mike Rejman,Kathryn Hill |
| Subject Matter | Health & social care |
Focus on…
The Mental Health Review Volume 9 Issue 3 September 2004 ©Pavilion Publishing (Brighton) 2004 17
Root Cause Analysis and
Mental Health Incidents
Suzette Woodward
Assistant Director of Patient Safety
National Patient Safety Agency
Mike Rejman
Assistant Director of Patient Safety
National Patient Safety Agency
Kathryn Hill
Assistant Director of Mental Health
National Patient Safety Agency
Introduction
Clinical governance: a framework through which NHS
organisations are accountable for continuously
improving the quality of their services and
safeguarding high standards of care by creating an
environment in which excellence in clinical care will
flourish.
‘Learning and applying the lessons’ when things
have gone wrong is one means to improve service
quality, but the current process for investigating
homicides committed by mental health service users
has been subject to criticism due to the length of time
they can take (up to six years), expense (up to £3
million), their sometimes adversarial nature that can
have a negative impact on staff, and often inadequate
attention to the needs of the families of both the
victims and the perpetrators. The same
recommendations are repeated across inquiries with
little evidence that lessons have been learnt across
the mental health community.
Certain organisational and cultural factors can
increase the risk of incidents happening (Department
of Health, 2000). Root cause analysis (RCA) is a
technique for undertaking a systematic investigation
that looks beyond the individuals concerned and
seeks to understand the underlying causes and the
organisational context in which the incident
happened. Retrospective and multidisciplinary in
approach, it is designed to identify the sequence of
events, working back from the incident.
To ascertain the suitability of RCA for use in mental
health incidents, the National Patient Safety Agency
(NPSA) evaluated a number of homicide inquires
where RCA had been deployed. This found that RCA
was generally well received: the focus on the system
rather than the individual was welcomed; the process
was considered less threatening than panel inquires and
therefore conducive to more honest responses; and the
skills, sensitivity and expertise of those conducting the
inquiry were considered paramount. It was concluded
that RCA was indeed appropriate for use in homicide
inquiries. Draft guidance is awaiting final approval and
NPSA is producing an information pack for local
services to help foster a more uniform approach to
independent inquires. In addition NPSA will conduct
annual thematic reviews of inquiry reports to ensure
that lessons that have implications across the service are
both understood and acted upon.
This article outlines the basic components of the
root cause analysis process which are more fully
described in the NPSA’s guidance Seven Steps to Patient
Safety (www.npsa.nhs.uk/sevensteps).
Learning and sharing safety lessons
When things go wrong, it is important that organisations
learn from them in order to prevent future incidents.
The NPSA is fostering a practical and systematic
process across the NHS of learning from patient safety
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