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Learning from patient safety incidents and ensuring you adhere to the duty of candour

Elaine Spencer Serious Incident Investigator Brighton and Sussex University Hospitals Trust spoke at today’s Patient Safety Incident Reporting, Investigation and Learning on:

• identifying serious incidents requiring investigating
• utilising root cause analysis methodology to investigations
• interviewing staff involved in serious incidents
• liaising with patients and families
• applying ‘being open’ principles

Abstract of Elaine’s talk 
This session will review the considerations and principles of being open with patients when things go wrong. In particular it will draw upon experience of investigating serious incidents in an acute NHS Trust. The essential steps in the process of investigation will be outlined including supporting patients and families, interviewing staff, and learning lessons. 

Understanding and appreciating the role of human factors (known as ergonomics) in safety incidents helps us to build better and safer systems of care, reducing the risk of future harm. Other safety critical industries such as rail, aviation and security have understood this for some time and healthcare can learn from these industries. 

The Duty of Candour has been introduced, in law, for NHS bodies. This duty criminalises the failure to notify and apologise to patients when harm has occurred. This session will explore its introduction and what it means in practical terms for clinicians and organisations.

Elaine's full presentation is available for download at the end of this page. 

Elaine Spencer: Serious Incident Investigator, Brighton & Sussex University Hospital Trust (BSUH) Elaine works within the Safety & Quality Team at BSUH investigating serious incidents and is currently leading on the introduction of the Duty of Candour. Elaine has previously worked as a consultant nurse in cardiology at Guys and St Thomas NHS Foundation Trust introducing and evaluating nurse-led services and as the clinical director of S&C Healthcare providing clinical and management services to the NHS. She has been involved in, designing, delivering and commissioning innovative services, including complex care pathways. Elaine has shared her knowledge and expertise widely as a public speaker, a lecturer and is widely published.

Future related events:

Investigating Incidents and The Duty of Candour
Tuesday 28 April 
Hallam Conference Centre, London

Root Cause Analysis Conference: Investigating & Analysing Patient Safety Incidents
Wednesday 24 June 
ICO Conference Centre, London

Investigating Incidents and The Duty of Candour
Thursday 25 June 
Cavendish Conference Centre, London

Leading your Organisation to Zero-Harm
Thursday 9 July 
Hallam Conference Centre, London


Download: Elaine Spencer full presentation

2 February 2015

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