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A Practical Guide to Serious Incident Investigation & Learning

Friday 13 September 2019
De Vere West One Conference Centre, London

A Practical Guide to Serious Incident Investigation & Learning
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Follow the conference on Twitter #NHSSeriousIncidents

“We all make mistakes. We should strive to avoid them, of course, but the fact of a mistake isn’t the biggest problem. It’s how we respond to them and how we learn from them, that’s what’s most important. And we must never let our fear of the consequences, stop us from doing the right thing.” Secretary of State for Health and Social Care Matt Hancock February 2019

“We want the NHS to be the safest healthcare system in the world….We also propose a focus on three principles that should underpin implementation of the strategy: a just culture, openness and transparency and continuous improvement.” NHS Improvement December 2018

“We know there are problems, for example, with how incidents are investigated and learned from. In our recent engagement to find out how we can improve the Serious Incident framework, people told us they were concerned about: providers’ lack of capability and capacity to carry out good quality investigations; the tendency to use investigation for the wrong purposes; the generally poor approach to patient and family involvement; and the fact that actions to reduce risks after the completion of an investigation are too often ineffective. We know from the Care Quality Commission’s (CQC’s) review of how the NHS responds to and learns from the care provided to patients who die that too often problems with care are not identified and the bereaved, who may have concerns, are not sufficiently supported.” NHS Improvement December 2018

This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the revised Serious Incident Framework which is currently post consultation and due for publication in Spring 2019, and the implications for serious incident investigation. The conference will update delegates on the National Learning from Deaths guidance and implementation in practice. There will be a focus on learning from serious incidents, ensuring the investigation findings lead to change and improvement.

This conference will enable you to:

  • Network with colleagues who are working to improve the investigation of serious incidents
  • 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 in line with the National Guidance
  • Update your knowledge with national developments including forthcoming revised 2019 Serious Incident Framework
  • 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
  • Develop your skills in Serious Incident Investigation: applying the serious incident framework and using skilled analysis to move the focus of investigation from acts or omissions of staff, to identifying the underlying causes of the incident
  • Identify key strategies for improving investigation of serious incidents
  • Gain CPD accreditation points contributing to professional development and revalidation evidence

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