Skip to content

Q logo

What is the positive change that has emerged through new collaborations or partnerships during Covid-19 that your project is going to embed?

Covid-19 has changed how organisations, departments, providers and independent organisations work together. Strengthening of relationships has enabled the conditions for curiosity and positive challenge to occur.

Covid-19 is impacting upon an ever-increasing demand on mental health services with anecdotal reports of increases in both homicides and suicides. The full impact of social isolation, employment and domestic stressors experienced by the community is yet to be fully understood.

Mental health homicides are investigated so that lessons can be learned effectively, common risks and opportunities to improve patient safety are identified and recommendations made for organisational and system learning.

Relationships that cross organisational boundaries and where challenge and a ‘critical friend’ approach is enabling solutions and changes in service provision to meet the needs of the population. Trust and psychological safety are needed to improve quality of homicide investigations and outcomes for our communities.

What does your project aim to achieve?

CQC Learning, candour and accountability (2016), describe a variety issues about investigation processes. Organisations often work in isolation, reviewing the care individual trusts and missing opportunities for identifying improvements in services and commissioning, often for patients with mental health or learning disability needs.

Producing high quality initial homicide investigations can be achieved by:

  • Working alongside to develop specialised homicide investigation knowledge and support
  • Enabling meaningful family involvement
  • Increasing internal resource to support the investigation
  • Focusing on system analysis and human factors
  • Providing lead role where investigations cross agencies and pathways of care
  • Sharing learning and improvements through system quality forums
  • Improving staff experience of investigation processes
  • Reducing costs of independently commissioned reviews
  • Enabling timely identification/actions to address contributory factors.
  • Aligning the current processes with the principles outlined in the Patient Safety Incident Response Framework.
  • Drawing on collaborative relationships to support commissioning decisions and equality of provision.

How will the project be delivered?

This project is looking to proactively improve the quality of initial investigations by supporting providers from the outset.

It is proposed that following the reporting of the homicide within the region, the region will work with the provider/system to identify the current homicide investigation expertise and where additional skills and resources are required. Successful funding would enable these resources to be provided to support and up skill the internal team who can become part of a peer network for future investigations.

The impact will be measured by:-

  • family and staff feedback
  • comparing the timeliness of reviews
  • system focussed recommendations that influence care pathways
  • reducing the number of repeat recommendations made
  • reducing costs of independent reviews
  • having a growing pool of people with skills and expertise

How is your project going to share learning?

The project will provide an opportunity to influence a culture of continuous learning at a system level. Supporting system partners by working alongside others with previous experience/skills in this area will foster local ownership of both issues and solutions.  Any cost savings from reducing the need for re-investigations could be diverted to support quality improvement approaches in embedding and measuring impacts of recommendations made.

In line with the operating model for ‘Q’ this project encourages connections with systems and communities, supports others and influences improvements, mobilising others to collaborate efficiently and spread improvements whilst developing skills and encouraging local ownership and learning.

Preventing homicides and suicides is a complex area where there are several multifactorial elements that are border reaching than health and social care.  Working collaboratively as systems to identify, own and address any contributory factors identified is a key part of prevention.

How you can contribute

  • Help identify people with skills and expertise in this area
  • Consider improvement lab approach to repeat recommendations and develop solutions

Plan timeline

31 May 2021 Engage with MH providers to learn from their experiences
31 May 2021 Engage with family and carer representatives
31 May 2021 Gap analysis of current skills in homicide reviews undertaken
30 Jun 2021 Identify system requiring input post event and scope investigation approach
30 Jun 2021 Scope skills and expertise available to support systems
31 Aug 2021 Provide training to upskill regional staff to form peer network.
31 Aug 2021 Providing development oppourtunities at governance and board level
31 Oct 2021 Utilise skills of QSG family/carers members to develop system actions
31 Oct 2021 Work alongisde system to complete investigation
31 Dec 2021 Evaluate family/carer experiences
31 Jan 2022 Evaluate impact of recommendations and sustained changes in practice


  1. Hi Michelle. Great to see your idea - unique and very interesting. I'm working with the Health Foundation to identify opportunities for collaboration in this year's Q exchange round. To get some feedback and perhaps generate some support, it might be worth linking in with two online groups - QI in mental health and the Human Factors group. Both may contain members who would be interested in your idea. Also, there are a few THF alumni and Q members that work for HSIB that might be interested - have a search in the community directory. I can also provide their names if you want to direct message. Good luck with your idea, Emma

    1. Many thanks for your suggestions, we will follow these up.



Leave a comment

If you have a Q account please log in before posting your comment.

Read our comments policy before posting your comment.

This will not be publicly visible

Please note that you won't be able to edit or delete comments once posted.