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A Practical Guide to Serious Incident Investigation & Learning

Working with and involving patients when an incident occurs

Susannah Hill

• learning from the lived experience
• how can we put patients at the heart of the process?
• how excellent engagement can produce better results for patients and Trust during
 serious incident investigations
• involvement in reviews and investigations


A brilliant talk from the Patient Perspective and how the importance of engagement and the importance of keeping the channels of communication open.
The virtual session sparked a very interesting discussion between Sue and the delegates discussing experiences and best practices. 


Mortality Governance, Meeting the National Guidance on Learning from Deaths, and the National Mortality Review Programme


Mr Gabriel Sayer
Associate Medical Director, Consultant General and Vascular Surgeon
Barking Havering and Redbridge University Hospital NHS Trust



• implementing the national framework for Identifying, Reporting, Investigating and Learning from Deaths in Care
• the national context - Learning From Deaths and the introduction of Medical Examiners
• developing Mortality Governance locally
• findings and learning from our regional mortality review programme
• implementing the CQC recommendations and new regulations on serious incident investigation at a local level – what we know so far
• serious incidents, learning from deaths, and Covid-19
• sharing information about deaths between providers: challenges and information

Gabriel Sayer's talk discussed the importance of the CQC, recommendations and how to use the new regulations and toolkits to learn and meet national guidance.