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

Dr Martin Farrier speaks at today's conferenceDr Martin Farrier speaks at today's conference

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.

Chair Dr Umesh Prabhu Consultant Paediatrician, Medical Director for more than 15 years, Medical Adviser for International Recruitment Wrightington, Wigan and Leigh NHS Foundation Trust opened the conference with an update on 'Improving the way organisations investigate, communicate and learn when things go wrong' and will discuss;

  • learning from the review into the quality of investigation reports
  • the new national guidance on learning from deaths: developing a standardised approach and enabling mortality governance
  • implementing recommendations on serious incident investigation
  • 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

Dr Umesh Prabhu's Biography

Currently working as Medical Adviser for Edgehill University for international medical recruitment, Patron of AvMA (Charity which helps patients who have suffered due to ‘Medical Negligence), also Member of Patient Safety Advisory committee of Datix.

Previous Employment

Medical Director, Wrightington Wigan and Leigh NHS Foundation Trust (April 2010 -2017)

Medical Director of Bury NHS Trust (1998 – 2003)

National Adviser for the National Clinical Assessment Service – NCAS (2003 – 2015)

Board Member, National Patient Safety Association, NPSA (2001 –2003)

Clinical Adviser, Health Care Commission (2001-2003)       

Consultant Paediatrician, Bury NHS Trust (1992 – 2010)

Clinical Director Paediatrics, Bury NHS Trust (1992 – 1998)

Inclusion, Equality and Diversity

Member Black and Minority Ethnic Advisory Committee of the GMC since 2000

Member of Equality and Diversity Committee of the British Medical Association (BMA) (2005-2014)

Previously Member of National Clinical Advisory Service and

Department of Health Equality and Diversity Committee

National Vice Chair of the British International Doctors Association (BIDA) (2001 – 2012)         

National Vice Chair of the British Association of Physicians of Indian Origin (BAPIO) (1998-2001) (

In 2017 March I left WWLFT to pursue my interest in patient safety in India and UK and to write my books and to help NHS by recruiting international doctors.

In 2015, Mr Simon Stevens, the CEO of NHS took me to meet the Queen for her Majesty’s 90th Birthday for my contribution to NHS, patient safety and medical leadership and inclusion and diversity.

2014 and 2015, I was voted as one of the top 50 pioneering BME leader (Black and Minority Ethnic) of NHS.

Patient safety, quality and Leadership

Following my own mistake in 1992, I developed keen interest in patient safety, quality and why doctors make mistakes.

Over last 25 years or so I have done lot of work of patient safety, medical errors, clinical governance, why doctors make mistakes, professional regulation, organisational governance, culture, leadership and institutional racism, subconscious bias and so on

I have given more than 200 lectures and conducted many workshops for doctors nationally and internationally on patient safety, quality, why doctors make mistakes, professional regulation, value based leadership, clinical governance and so on and advised and helped more than 500 doctors, mostly Indian doctors in UK.

In 2010, I was appointed as the Medical Director of Wrightington Wigan and Leigh FT (WWLFT).

With the help of CEO Mr Andrew Foster and the Board and excellent staff we transformed the Trust and reduced harm to patients by 90% and the Trust received 45 awards and 450 less patients die each year and all quality measurements have improved. Complaints reduced by 35%.

For staff happiness, the Trust was bottom 20% in 2011 and by 2016 the Trust became the third best Trust in the country!

Financially the Trust has been stable. The Trust has 300 patient safety champions and excellent governance.

The Trust focused on culture, values, value based leaders and implemented robust governance and accountability. The Trust also has excellent staff and patient engagement.  The Trust leadership is diverse and reflects the ethnicity and gender of the Trust medical workforce.

The success of the Trust is simply because of hard working staff and culture of staff happiness. The Trust implemented patient safety culture and learning and supportive culture but also culture of accountability for all.

In 2015, CQC Board invited me and Mr Foster to give a presentation to the Board and this is the link to that presentation.

Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust spoke on 'Mortality Governance and Meeting the new National Guidance on Learning from Deaths' and covered;

  • implementing the national framework for Identifying, Reporting, Investigating and Learning from Deaths in Care
  • developing mortality governance in your organisation
  • Death Certification, Case Record Review and Investigation
  • a step by step guide to mortality casenote review
  • using the new national dashboard for data publication
  • implementing the learning to change practice


Dr Farrier comments: "3% of deaths are preventable
Review deaths - Concentrate on Non ITU / Non care of the dying pathway
Be aware of bad statistics; use real data to measure, understand and improve 
Dressing differently is a social change badge to prevent cdiff
Introduce a Checklist Social Changes and support your staff so that they can provide the safest and best care
To change the habits of your staff, help them and guide them and social change and have champions
Governance will only take us so far in change-need to develop social change" 

Dr Martin Farrier's Biography

Martin qualified in 1992 from Charing Cross Medical School. He initially trained as a GP, before becoming a paediatrician. He took his first post as a Consultant in 2001 at Wigan where he specialised in Neonates and Cardiology. His interest in Mortality was initiated during his work as Deputy Medical Director, and more recently has continued in his role as Clinical Director for Quality. Working to reduce mortality has become an important part if his work at Wigan. The work has led to quality improvement work throughout the Trust. He is now the Associate Medical Director at Wigan.

In his time away from work, Martin is married with 3 children. However, he likes nothing more than running, cycling and swimming, ideally all together on a Sunday morning.

Future conferences of interest:

Investigation of Deaths in NHS Trusts: Implementing the NQB & CQC Recommendations
Monday 2 October 2017 
De Vere West One Conference Centre, London

Patient Leadership Summit
Friday 15 December 2017 
De Vere West One Conference Centre, London

Sepsis: Implementing the New National Quality Standard
Monday 22 January 2018 
De Vere West One Conference Centre, London

25 September 2017


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