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A Practical Guide to Serious Incident Investigation & Learning

Training dates throughout the year:

Tuesday 12 Oct 2021
Friday 28 Jan 2022

Follow the conference on Twitter #NHSSeriousIncidents

Find out more about virtual attendance

This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development and implementation of the New Patient Safety Incident Response Framework (previously known as the Serious Incident Framework) which has now been published for the early adopter sites as introductory guidance. NHS Improvement will then work with a small number of early adopters to test implementation. For all other organisations the PSIRF is being published for information only and using learning from the pilot sites, resources and guidance will be developed to support organisations to adopt and implement PSIRF, with an expectation that providers and local systems will begin transitioning to the PSIRF from Spring 2022. The conference will also update delegates on best current practice in serious incident investigation and learning, including mortality governance and learning from deaths. There will be an extended focus on ensuring serious investigation findings lead to change and improvement.  

The NHS has systems to support the reporting of safety incidents and from these reports it learns how to make healthcare safer. However, despite these efforts and the continuing advances in patient care, the inherent risks and complexity of healthcare mean an NHS entirely free of incidents is an unrealistic expectation. Identifying incidents, recognising the needs of those affected, examining what happened to understand the causes and responding with action to mitigate risks remain essential to improving the safety of healthcare. Creating systems that do this is a complex, challenging and continuous endeavour that requires the right skills, processes and – perhaps most importantly – behaviours. We know that organisations are struggling to deliver good quality investigations that consistently support the reduction of risk. As a result, opportunities to reduce patient safety incidents can be missed.

Patient Safety Incident Response Framework 2020 An introductory framework for implementation by nationally appointed early adopters March 2020

“Organisations and local systems should review this document and begin to think about what they will need to do to prepare ahead of the full introduction of the PSIRF in 2022.”

NHS England 2021

“To support the NHS to further improve patient safety, we are preparing for the introduction of a new Patient Safety Incident Response Framework (PSIRF), outlining how providers should respond to patient safety incidents and how and when a patient safety investigation should be conducted.”

NHS England 2020

“This introductory Patient Safety Incident Response Framework responds to calls for a new approach to incident management, one which facilitates inquisitive examination of a wider range of patient safety incidents “in the spirit of reflection and learning” rather than as part of a “framework of accountability”. Informed by feedback and drawing on good practice from healthcare and other sectors, it supports a systematic, compassionate and proficient response to patient safety incidents; anchored in the principles of openness, fair accountability, learning and continuous improvement.

Patient Safety Incident Response Framework 2020 An introductory framework for implementation by nationally appointed early adopters March 2020

This conference will enable you to:

  • Network with colleagues who are working to improve the investigation of serious incidents
  • Ensure your approach to Serious Incident Investigation is in line with the NHS Patient Safety Strategy
  • Update your knowledge with national developments including the New Patient Safety Incident Response Framework
  • Understand developments in the PSIRF early adopter sites 
  • Reflect on the management and investigation of serious incidents involving Covid-19 
  • Learn from outstanding practice in the development of serious incident investigation and mortality review
  • Reflect on the perspectives of a patient who has been involved in a serious incident 
  • Develop a risk based response to incident investigation
  • Reflect on the development of mortality governance within your organization and understand the challenges of Covid-19
  • Understand how to work with staff to ensure a focus on learning and continuous improvement
  • Develop your skills in Serious Incident Investigation: applying the human factors to move the focus of investigation from acts or omissions 
  • of staff, to identifying systems improvement
  • Identify key strategies for improving investigation of serious incidents
  • Gain CPD accreditation points contributing to professional development and revalidation evidence

Chair & Speakers Include:

Mike O'Connell

Legal Services Practitioner

Professor Helen Young

Executive Director of Patient Care & Service Transformation/Chief Nurse
South Central Ambulance NHS Foundation Trust

Lorraine Cardill

Safety and Learning Lead, Midlands and East
NHS Resolution

Jo Mason-Higgins

Head of Claims, Complaints and Patient Safety Investigations Lead for Duty of Candour
Gloucestershire Hospitals NHS Foundation Trust

Virtual Attendance

Our online virtual events include a combination of live webcam presentations, training materials, video sessions and interactive exercises and discussion.

All you need is a quiet space, a good internet connection and PC or laptop with camera and microphone to allow you to see, hear and speak to the facilitator and other delegates. We will provide full instructions for accessing the platform along with login details. 

For the full benefits and all our virtual training titles click here

Virtual Training

Exhibition & Sponsorship Packages

This conference offers a valuable opportunity for industry suppliers to personally meet with their target audience where they will have time to talk and demonstrate the benefits of their products. High quality specialist audiences make having a presence at our events a highly targeted and cost effective marketing channel.

Why Exhibit?

Having a presence at this event will give you the opportunity to:

  • Demonstrate your product, system or service
  • Network and engage with your key audience  
  • Generate new business leads
  • Gain exposure for your brand and raise the profile of your organisation
  • Understand the current needs of your audience and challenges they’re facing
  • Update your knowledge of national policy and local developments  


Contact Carolyn Goodbody for exhibition and sponsorship prices, or to discuss a tailored package to suit your needs and budget.

Fee Options

NHS & Public Sector



Voluntary sector & charities



Commercial organisations



Virtual Training



(Prices in brackets include VAT)


Additional delegate discount:

A discount of 15% will be applied to fees for any extra delegates.

Online discount:

A discount of 10% will be applied if you pay using the website.

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Supporting Organisations