Date: Wednesday 14 May 2025
Time: 2-3.30pm
Location: Online (Teams)
Attendees learnt what our mental health investigations and safety recommendations mean for different people including patients, health and care staff, commissioners and charities.
Resources
- Mental health care in inpatient settings investigation reports
- Webinar slide deck
- Webinar recording
- Webinar chat and useful links (see below)
Webinar chat
Attendees participated in an active Microsoft Teams chat throughout the event. This centred around the following themes:
- reflections on learning and improvement
- reflections on mental health care service provision
- reflections on service user/patient and family involvement
- reflections on the Patient Safety Incident Response Framework (PSIRF)
- reflections on staff speaking up and the impact of culture on investigation processes.
In addition, some further insights were suggested to HSSIB for future investigation, which have been shared with our investigation and insights team.
A thematic summary of the unedited chat is available on request for those in attendance at the webinar. Please contact Nichola Crust, Senior Safety Investigator, for further information: nichola.crust@hssib.org.uk.
Useful links
The following links were shared in the chat by attendees during the live webinar.
- HSSIB: We want to hear people's experiences and concerns about patient safety to inform our prioritisation of future investigations.
- Staying safe from Suicide: national best practice guidance was published in April by NHS England.
- Action Against Medical Accidents (AVMA) is the UK charity for patient safety and justice.
- NHS England guidance that explains the role of the Family Liaison Officer (FLO) and Investigating Officer (IO).
- An open access paper published by Frontiers in Health Services that touches on many of the points raised in this discussion.
- Royal College of Psychiatrists report: Supporting mental health staff following the death of a patient by suicide - a prevention and postvention framework.
- The term restorative learning is explained and conceptualised in this open access paper published by Frontiers in Health Services.
- HSSIB reports shared in the chat: The impact of staff fatigue on patient safety and Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare.
- Care Quality Commission (CQC) were keen to hear peoples experiences around how the CQC respond to concerns.
- Nurse Education Today journal article: Care erosion in hospitals - problems in reflective nursing practice and the role of cognitive dissonance.
- NHS Confederation programme to support teams working at the interface between acute emergency departments and mental health to develop solutions to local issues, involving 12 regions.
- BBC News article: Mental health complainants fear reprisals - study.
Speakers
Dr Dorit Braun, OBE
Project Coordinator – Making Families Count
Dorit retired in 2019, having worked as a charity chief executive and in a variety of senior management and governance roles in the social care and family support sectors. Following a very traumatic family bereavement Dorit is active in trying to improve mental health care and the ways NHS staff and organisations learn from deaths. Dorit became a member of Making Families Count in 2020, where she coordinated a mental health focused project – ‘Life beyond the cubicle’ – which has developed, tested and published eLearning materials. These materials aim to contribute to improving patient care and reducing harm, deaths and near misses that might occur during mental health crises. The resources are free to the health and social care workforce on the NHS Learning Hub. Dorit is also an artist, exhibiting from time to time.
Gemma Byrne
Policy and Influencing Manager – Mind
Gemma leads Mind's campaigns on inpatient care and the Mental Health Act. Gemma joined Mind in 2021 and has worked on a wide range of policy issues affecting young people and adults accessing NHS mental health services. In her role at Mind, Gemma has worked closely with HSSIB to support the investigations into mental health hospitals, making sure people with lived experience were represented in the investigations. Before joining Mind, Gemma worked in the policy team at Citizens Advice on issues including debt, housing and essential services.
Dr Rachel Gibbons
Consultant Psychiatrist and Consultant Medical Psychotherapist; Vice Chair of the Psychotherapy Faculty – Royal College of Psychiatrists
Dr Rachel Gibbons is an expert on the psychodynamics of suicide and homicide, with a focus on their impact on clinicians and the bereaved. Over the past 20 years, she has worked in the NHS as a consultant psychiatrist, medical psychotherapist, psychoanalyst, and group analyst. She chaired the Patient Safety Group at the Royal College of Psychiatrists (RCPsych) for four years and recently stepped down from chairing the Working Group on the Effect of Suicide and Homicide on Psychiatrists. She has led the development of two RCPsych guidance documents for all mental health organisations in the UK on the pastoral care of mental health staff following a patient's death by suicide and a patient-perpetrated homicide. The guidance on suicide is now incorporated into England’s National Suicide Prevention Strategy (2023). She is currently Vice Chair of the Psychotherapy Faculty at the Royal College of Psychiatrists.
Charlotte Haworth Hird
Partner – Bhatt Murphy Solicitors
Stephen Hinchley
Policy and Public Affairs Lead – VoiceAbility
Stephen is policy and public affairs lead for VoiceAbility, a leading provider of advocacy services (including independent mental health advocacy) in England and Scotland. Stephen has been working on reforms to the Mental Health Act and inpatient mental health services since he joined VoiceAbility in February 2020.
Alistair Smith
Senior Solicitor – Watson Woodhouse Solicitors
Alistair has been a qualified solicitor for over 30 years, dealing mainly with litigation matters including sexual and physical abuse claims. Alistair was the driving force behind the change in rules in the Criminal Injuries Compensation Authority (CICA) scheme regarding the ‘same roof rule’. Alistair works with families who have experienced the death of a family member where mental health was involved either as an inpatient or in the community. This has included supporting families through independent investigations commissioned by NHS England. Alistair won the Outstanding Achievement Award at the Northern Law Awards 2024. This award recognises individuals and organisations that have demonstrated excellence, innovation and dedication in various areas of law.
Rachel Wakefield
Regional Chief Allied Health Professional – NHS England (East of England); National Portfolio Holder for Allied Health Professionals in Mental Health, Learning Disabilities and Autism
An occupational therapist by background, Rachel specialised in mental health rehabilitation, including with people using secure services. Her provider experience has combined professional and clinical leadership with responsibilities for quality. She has a particular research interest in the role of allied health professions in patient safety and is a Visiting Professor at Anglia Ruskin University in the Faculty of Health, Medicine, and Social Care.
Paul Whiteing
Chief Executive Officer – Action against Medical Accidents (AvMA)
Paul is an experienced senior leader and former chief executive officer of a telecoms regulatory body. Prior to joining AvMA, Paul was a lead ombudsman and director of casework at the Financial Ombudsman Service (FOS), where amongst other responsibilities, Paul led FOS’ work on vulnerable customers and the service they received. Paul’s focus at AvMA has been on creating, and now implementing, the five-year strategy (2024-29) and at the same time ensuring that the charity has a long-term plan to remain financially sustainable. Outside of work, Paul likes to spend time with his family, is an avid reader, takes a keen interest in current affairs and enjoys riding his mountain bike on the South Downs.
Eelke Zoestbergen
Quality Lead – NHS Somerset Integrated Care Board
Eelke has worked in the public sector since 2002. First in the police service in quality assurance (including a focus on equality an inclusion, as well as mental health and learning disabilities) and then from 2012 in the Office of the Police and Crime Commissioner as a commissioner (victim services). In 2015 she moved to Somerset County Council as a joint lead commissioner for learning disability and autism in a joint NHS/local authority role. After this she joined NHS Somerset Integrated Care Board in 2019 as a quality lead (mental health, learning disability and autism) focusing on quality, improvement and patient safety.
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