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

Monday 25 September 2017
De Vere West One Conference Centre, London

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

“A service that is safe and well-led will see every serious incident as an opportunity to improve, will support staff to raise concerns within a culture of learning not blaming, and will recognise the need to involve patients and their families when reviewing why and how incidents have occurred. Unfortunately this is not happening everywhere. The needs of patients and their families are not always given priority and the analysis of events sometimes fails to identify the underlying causes that led to the incident in the first place. Investigating serious incidents is a powerful way the NHS can learn from mistakes, reduce or eliminate the risk of harm or death, and improve patient care.” Prof Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission

“Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.” CQC, 13 December 2016

The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level…there is not a single NHS trust that is getting it completely right currently”. Prof Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission HSJ, December 2016
 

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This course is now full. We are running this event in London on Tuesday 25 — Wednesday 26 July 2017, Tuesday 19 — Wednesday 20 September 2017 and Tuesday 28 — Wednesday 29 November 2017

In Manchester on Wednesday 12 — Thursday 13 July 2017

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