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Learning from Serious Incidents: Implementing the National Guidance on Learning from Deaths

Monday 5 February 2018
De Vere West One Conference Centre, London

Learning from Serious Incidents: Implementing the National Guidance on Learning from Deaths
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“The Committee supports the recommendations made in the CQC’s report that training should be provided to staff across the health service in England on how to conduct investigations.” Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, 2017

“It is clear from the evidence reviewed during the course of this inquiry that the investigative processes in the health service in England remain obscure and difficult to navigate for patients and families. As a result, patients and families are excluded by the system, which must become open and learning-focused if investigations are to lead to positive changes in the system. Families and patients should, as a matter of course, be included in investigations and should feel confident that lessons will be learned as a result of clinical incidents.” Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, 2017

In March 2017 the National Quality Board has published National Guidance on Learning from Deaths providing a framework for NHS Trusts on identifying, reporting, investigating and learning from deaths of people in their care. This national conference looks at the practicalities of Serious Incident Investigation and the investigation of deaths in light of the new national guidance.

“Understanding and tackling this issue will not be easy, but it is the right thing to do. There will be legitimate debates about deciding which deaths to review, how the reviews are conducted, the time and team resource required to do it properly, the degree of avoidability and how executive teams and boards should use the findings. This first edition of National Guidance on Learning from Deaths aims to kickstart a national endeavour on this front. Its purpose is to help initiate a standardised approach, which will evolve as we learn” National Quality Board March 2017

This conference will enable you to: 

  • Network with colleagues who are working to improve the investigation of serious incidents and death 
  • Learn from outstanding practice in the development of serious incident investigation and mortality review   
  • Reflect on the perspectives of bereaved families and carers and understand how you can engage them and recognise their insights as a vital source of learning
  • Update your knowledge with national developments including the March 2017 NQB guidance on learning from deaths
  • Reflect on the development of mortality governance within your organization 
  • Understand how to work with staff to ensure a focus on learning and continuous improvement  
  • Identify key strategies for improving investigation of serious incidents  
  • Gain cpd accreditation points contributing to professional development and revalidation evidence

100% of delegates at the last conference on this subject would recommend the event to a colleague

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