Serious incidents, such as patient suicide, profoundly impact clinicians. In mental health settings, these events are uniquely distressing. Despite policy shifts towards learning from serious incidents, many doctors report inadequate support and significant emotional distress. Resident doctors, already vulnerable to burnout and emotional exhaustion, are particularly at risk.

This study aimed to understand resident psychiatry doctors’ experiences of serious incidents. It sought to gather in-depth insights about how resident psychiatrists navigate the serious incident process, and the effect the process has on their professional and personal lives.

A qualitative study recruited 10 participants via email in 1 National Health Service (NHS) trust. Semi-structured online interviews were audio-recorded, transcribed and analysed using Braun and Clarke’s six-phase thematic analysis, employing an iterative, constant comparative approach.

Descriptive characteristics of the participants are reported. Three overarching themes were identified: (a) when the process becomes the experience, with subthemes focusing on how open and transparent the investigation process was, about communication during the process and how doctors felt the process impacted their clinical role; (b) from theory to practice: when training meets reality. Subthemes here reflected on whether resident doctors felt prepared and knowledgeable about the process. There was also focus on the experience itself being a learning opportunity; (c) the emotional undercurrents: trauma, grief and support. Here the subthemes focused on the emotional toll of an incident and investigation, the grief and wider impact of a patient death and lastly, the need for support to resident doctors including supervisor and peer-to-peer support. Themes are reported accompanied by verbatim quotes from participants.

Findings confirm prior studies investigating the negative impact of serious incidents on resident doctors’ well-being and career confidence, highlighting the need for robust support. The study adds to the literature through emphasising the inadequacy of current support and highlights rectifiable issues such as the need for structured peer support and improved supervisor/resident training for emotional and professional complexities. Future research should compare these findings with experiences under the new Patient Safety Incident Framework (PSIRF) system to assess improvements.

This study explored the root causes of deaths by suicide among patients under the care of a mental health trust. Thematic analysis was carried out to identify themes from the serious incident reports for patients between 1 January 2017 and 31 July 2018.

In total, 48 cases were reviewed. Three main themes emerged from this study: patient-, professional- and organisation-related factors. The majority of the deaths were caused by patient-related factors, particularly exacerbation of the patient's mental health condition.

This study provides insight into perceived causes of death by suicide among mental health patients. It is hoped that this will, in turn, influence the manner in which decisions, policies and resource allocation are carried out to further prevent and reduce the incidence of suicide, particularly among mental health patients.