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News and updates from today's Learning from Serious Incidents conference

Following the chairs introductions, Dr Sunil Gupta GP and Clinical Lead for Quality and on the Governing Body of Castle Point and Rochford CCG Advisory Group Member Healthcare Safety Investigation Branch, opens the conference with a session on 'Improving the way organisations investigate, communicate and learn when things go wrong' and discusses:

• learning from the CQC review into the quality of investigation reports
• help and encouraging improvement
• the need for a step change in the way that serious incidents are investigated and managed in the NHS
• the developing role of the Healthcare Safety Investigation Branch

In his presentation Dr Gupta placed emphasis on engaging staff in investigating incidents and not beating them up over human error mistakes.  He said patient safety investigations need a "just culture where  staff are not punished for carrying out actions of a reasonable person under the same circumstances."

Full PowerPoint presentation.

Dr Sunil Gupta is a GP and was a member of the Expert Advisory Group on the Healthcare Safety Investigation Branch. He has been interested in improving patient safety for many years and has been a member of the NHS England Primary Care Patient Safety Group and a member of the East of England Clinical Programme Board for Patient Safety. His present roles include GP Trainer, Examiner for the Royal College of General Practitioners and member of the Governing Body of Castle Point and Rochford Clinical Commissioning Group. Other roles include member of the East of England Clinical Senate, member of the NICE Quality Standards Advisory Committee and representative of the Essex Faculty at the Council of the RCGP. He is also a GP Advisor for CQC inspections of General Practices as well as GP Advisor for the RCGP Special Measures Support Team. Other previous roles include Clinical Advisor on Mental Health and Dementia for NHS England Midlands and East Region, Accountable Officer of Castle Point and Rochford CCG and a member of Health Education East of England Board. He has collected a lot of helpful resources on patient safety at http://www.southessexgptraining.co.uk/patient-safety and http://www.southessexgptraining.co.uk/patient-safety/patient-safety-investigations

 

Prof Helen Young Chief Nurse/Director of Nursing and Midwifery Birmingham Women’s NHS Foundation Trust continues the morning with an extended session on 'Prioritisation of incidents that require full investigation and developing methods for managing and learning from other types of incident', focusing on:

• developing criteria for full investigation under the serious incident framework
• good practice in the investigation of near misses
• ensuring a proportionate response: methods for managing and learning from other types of incidents
• ensuring conclusions in investigations will lead to inform learning and change practice
• key steps within the Serious Incident Framework

Full PowerPoint presentation.

After training as a nurse at Westminster Hospital in London, Helen held Sisters posts in Surgery and Critical Care and Medicine before setting up a Nurse Led Development Unit with Leeds University. This fuelled her passion for developing nursing practice, education and leadership. She went on to complete her Masters in Education and take on roles as Head of Practice Development in Guys and St Thomas and then Chelsea and Westminster.

Helen has held Deputy and Chief Nurses roles in a number of large acute Trusts including East Kent, Conwy & Denbighshire, Croydon University Hospitals Trust, Oxford University Hospitals Trust, Kings College Hospital FT, as well as six years in a national role as Clinical Director and Chief Nurse for NHS Direct.

She is currently Director of Nursing and Midwifery at Birmingham Women’s NHS Foundation Trust.

Helen is a Visiting Professor at BCU, Florence Nightingale Leadership Scholar and Harvard University Graduate

She is a also a Trustee of Dorothy House Hospice and President of her local Soroptimist  International Club, and organisation that works to empower, educate and enable women and girls in the UK and internationally. 

 

Melanie Ottewill Head of Clinical Investigations Brighton & Sussex University Hospitals NHS Trust concludes the morning sessions by discussing 'Working with patients and families following an incident and routinely involving patients and families in the investigation', and discusses:

• working with patients and families when an incident occurs
• involving patients and families in the investigation
• applying ‘being open’ principles
• our experience in Brighton and Sussex

Melanie gave tips and advice for talking open and honestly to patients and families following an incident and during investigation.  She said it is so important to be yourself not the coorporate face of your organisaiton.  She said ask questions and be curious as you naturally would, be sincere; don't say you understand (if you can't possibly), don't say 'we' i.e. "we are sorry" say; "i am so sorry ..." If you are you and stay human it will help repair trust. 

Full PowerPoint presentation.

Pre-Event Presentation abstract:

This presentation will cover working with patients and families when an incident occurs through to sharing the final report, learning and actions being taken to prevent the same thing happening again. The presentation will be practically focussed on applying being open principles in practice drawing on the speakers experience as Head of Clinical Investigations at Brighton and Sussex NHS Hospitals Trust.

Melanie is a registered nurse and qualified social worker and has worked in both statutory and non-statutory settings. She has worked in Brighton & Sussex University Hospitals NHS Trust for over 15 years in different clinical settings as well as posts such as Joint Head of Complaints and Head of Clinical Investigations. Melanie has been investigating Serious Incidents for over 10 years and has completed over 100 investigations. She is passionate about increasing the involvement of patients and families in investigations and on promoting a culture which enables and promotes our Duty of Candour.


Future events of interest:

Root Cause Analysis: 2 Day Intensive Training Course
Tuesday 31 January 2017 — Wednesday 1 February 
Doubletree, Hilton London, West End, London

Root Cause Analysis: 2 Day Intensive Training Course
Wednesday 22 February 2017 — Thursday 23 February 
The Studio Conference Centre, Birmingham

Root Cause Analysis Review & Quality Assurance Masterclass
Friday 28 April 2017 
De Vere West One Conference Centre, London

Root Cause Analysis: 2 Day Intensive Training Course
Wednesday 24 May 2017 — Thursday 25 May 
Doubletree, Hilton London, West End, London

Investigation of Deaths & Serious Incidents in Mental Health Services
Friday 10 February 
De Vere West One, London

Learning from Serious Incidents: Implementing the CQC Recommendations
Thursday 23 February 
The Studio Conference Centre, Birmingham

Complaints Handling, Investigating, Resolving and Learning for Clinicians and Managers in Health and Social Care
Tuesday 25 April 
De Vere West One Conference Centre, London


7 December 2016

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