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A Practical Guide to Serious Incident Investigation & Learning

Monday 3 December 2018
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

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 this year, 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.

“The NHS conducts patient safety investigations after things go wrong in patient care to learn from these events and to inform changes to prevent them happening again. Compelling evidence from patients, families, carers and staff has revealed weaknesses in the way NHS organisations investigate, communicate and learn when things go wrong. NHS Improvement March 2018

“Many reports and reviews highlight that NHS organisations struggle to routinely underpin their investigations with these principles: investigations do not always appropriately involve and support patients, families, carers and staff; many are undertaken by staff without the necessary time and expertise; some focus too narrowly on care in specific settings and do not consider the care a patient received from several different organisations; too often they do not follow a systems-based methodology; and too many make weak recommendations that do not effectively address problems in care.” NHS Improvement March 2018

Key factors contributing to poor investigations identified by NHS Improvement include

  • Defensive cultures and lack of trust
  • Inappropriate use of the Serious Incident process
  • Misaligned oversight and assurance processes
  • Lack of time and expertise
  • Inconsistent use of evidence-based investigation methodology


The conference will also update delegates on effective involvement of families and carers in the investigations of serious incidents including the July 2018 Guidance for NHS trusts on working with bereaved families and carers.

“Under any circumstances, losing a loved one can be traumatic, and the level of support provided to families by the NHS at this time can make a considerable difference. However, there are families whose loved ones have died in untoward circumstances and whose subsequent experience has been deeply at odds with what we expect from our highly valued NHS… We urge you to embrace this guidance. It has the potential to produce the dramatic change the CQC proposed; reducing trauma to the bereaved; and giving real meaning to the term ‘learning from deaths’. Families involved in the Learning from Deaths Steering Group July 2018

The Committee supports the recommendations made in the CQC’s report that training should be provided to staff across the health service in England on how to conduct investigations.” Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England, 2017

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 2018 National Guidance
• Update your knowledge with national developments including the revisions
   to the 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
• Identify key strategies for improving investigation of serious incidents
• Gain cpd accreditation points contributing to professional development and
   revalidation evidence

100% of delegates at the last conference on this subject would recommend the event to a colleague

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