The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis (4 January 2024)

Summary

Serious incident management and organisational learning are international patient safety priorities. However, little is known about the quality of suicide investigations and the potential for organisational learning. Suicide risk assessment is acknowledged as a complex phenomenon, particularly in the context of adult community mental health services. Root cause analysis (RCA) is the dominant investigative approach, although the evidence base underpinning RCA is contested, with little attention paid to the patient in context and their cumulative risk over time. This study reviewed research in this area and found that recent literature proposes a Safety-II approach in response to the limitations of RCA.