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

This national conference looks at the practicalities of Serious Incident Investigation and the investigation of deaths ensuring adherence to the national guidance on identifying, reporting, investigating and learning from deaths of people in their care.

“The changes that we at the CQC have made to our inspection approach give closer scrutiny to the way in which NHS trusts identify patients who have died and decide which reviews or investigations are needed. They also involve a thorough review of how hospitals go about those investigations, how they ensure the involvement of families and carers, and how they share learning across the organisation to help drive improvements.The NHS is the first healthcare system to commit to reporting and publishing information on the number of avoidable deaths in its hospitals and the work that is being done by individual NHS trusts to learn from those deaths. This new level of transparency will be central to improving care and ensuring the safety of the NHS services we all rely on.”
Professor Ted Baker, Chief Inspector of Hospitals, Care Quality Commission, December 2017

“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

We have often found poor systems and processes to manage risk so that safety incidents are less likely to happen again…Poor performance for safety is ofen a result of problems with a practice’s overarching systems and governance, which results in safety being a low priority and a culture that does not value ongoing learning from safety incidents.” Care Quality Commission October 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