#7184 An in-depth qualitative study of factors contributing to serious incidents in an NHS psychiatry service for adults with learning disability

<h3>Aims</h3> People with learning disabilities experience significant healthcare disparities and preventable harm. In-depth analysis of contributors to healthcare-related adverse events for this cohort is lacking. Serious incident investigation reports contain rich data, but learning is often confined to individual cases and lessons learnt are mainly shared with those who are involved in the incidents. This study aimed to address this gap by exploring factors contributing to serious incidents involving people with learning disabilities receiving mental healthcare and analysing recurring themes at sharp and blunt ends of care. <h3>Methods</h3> Thirty anonymised serious incident reports from the adult learning disability service of an NHS mental health Trust, between 2014–2023 were analysed using the Yorkshire Contributory Factors Framework, followed by reflexive thematic analysis to elicit patterns across factors. This qualitative approach enabled nuanced themes to emerge from the data. <h3>Results</h3> Across 30 reports, a total of 606 discrete contributory factors were identified, spanning sharp-end errors and blunt-end latent conditions. Situational factors, including managing behaviours and staff competency gaps, were most common (n=187, 31%). Other factors included active failures e.g. slips, lapses, mistakes and violations (n=109, 18%), organisational influences (n=107, 18%), information flow issues (n=75, 12%), concerns about working conditions (n=62, 10%) and cultural factors such as reluctance to speak up and tolerance of protocol deviations (n=51, 8%). External factors were also identified (n=15, 2%). Thematic analysis identified recursive interactions between factors across levels, with systemic issues shaping frontline performance. Marginalisation of patients, overburdened staff, strained resources, and unsafe cultures aligned to permit errors. Fragmented systems and reliance on temporary staff inhibited transparent incident response. The absence of cultural and external factors in some investigations illustrated ongoing concerns regarding the depth of investigations, as conducted in the NHS. <h3>Conclusion</h3> People with learning disabilities experience serious incidents caused by contributory factors from multiple sharp and blunt-end factors. Systemic organisational, cultural and external factors reinforce entrenched inequalities. Collaborative, compassionate, socially just and inclusive approaches are essential to improve safety. Resourcing services adequately and improving the quality of investigations are also part of the critical changes paramount to addressing health inequalities in this vulnerable population.