Root Cause Analysis and Mental Health Incidents

Abstract

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 Draft guidance is awaiting final approval and NPSA is producing an information pack for local services to help foster a more uniform approach to independent inquires.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).