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This timely virtual conference focuses on implementing the Patient Safety Incident Response Framework in maternity services following the publication of the Ockenden Review into maternity services at Nottingham University Hospitals NHS Trust.
The Ockenden Review highlighted serious and repeated concerns around maternity governance, investigation quality, learning, training, culture, communication and the failure to listen to women and families. The report found that effective PSIRF implementation in maternity services depends on workforce capacity, protected time, appropriate training, compassionate engagement, high-quality learning responses and sustained investment. It also called for stronger role-specific PSIRF training, clearer feedback to families and greater consistency in the quality and format of investigation outputs across MNSI, PMRT and local PSIRF processes.
“When leadership, governance and culture are not robust: poor practice is not investigated; learning is not integrated; and mothers and babies are failed by an organisation they should be able to rely upon absolutely during a period of acute vulnerability in their lives… Safe and equitable care must now be the only acceptable standard.From my conversations with women and staff across the country I know that true excellence relies on empathetic leadership, individualised care, and an unwavering commitment to systemic equity. The expectations families bring to maternity care are, in truth, modest: competence, honesty, timely intervention and safety, with women receiving dignified and kind treatment from their first contact with maternity services through to their discharge and health-visitor provision.”
Donna Ockenden, Chair of the Independent Maternity Review 24th June 2026
“Like many other Trusts NUH has struggled to implement PSIRF. In maternity, the policy for including incidents is vague, resulting in under reporting. There has been insufficient workforce capacity to undertake training and investigations, or to participate in learning or reflective practice, with a lack of funding and immature skills hindering the shift to a just culture.”
Ockenden Report FINDINGS, CONCLUSIONS AND ESSENTIAL ACTIONS from the Independent Review of Maternity Services at Nottingham University Hospitals NHS Trust 24th June 2026
This conference will support maternity services to move beyond compliance and develop a practical, compassionate and maternity-specific approach to PSIRF. The day will examine how maternity services can strengthen their patient safety incident response plans, understand their maternity incident profile, choose the right learning response tools, involve women and families meaningfully, and ensure learning leads to measurable improvements in safety.
The programme will include practical sessions on applying PSIRF in maternity governance, improving the quality of maternity learning responses, using AARs, MDT reviews, swarm huddles and SEIPS, strengthening compassionate engagement after harm, and developing safety actions that address system weaknesses rather than simply revising policies. There will also be a focus on the relationship between PSIRF, MNSI, PMRT, Duty of Candour, complaints, claims, inquests and Board assurance.
The conference is particularly relevant to Directors and Heads of Midwifery, maternity governance leads, maternity patient safety specialists, obstetric and neonatal safety leads, LMNS and ICB quality teams, patient safety partners, complaints and claims teams, legal services, risk managers and Board maternity safety champions.
Learning Outcomes
By attending this conference, delegates will be able to:
Understand the implications of the Ockenden Review for PSIRF implementation in maternity services
Review the key requirements of the Patient Safety Incident Response Framework and Patient Safety Incident Response Standards
Develop a maternity-specific patient safety incident response plan informed by local incident profiles, complaints, claims, staff concerns, family feedback and clinical outcome data
Strengthen compassionate engagement and involvement of women, partners, families and staff following maternity patient safety incidents
Understand how PSIRF interacts with Patient Safety Incident Investigation where appropriate, MNSI, PMRT, Duty of Candour, complaints, claims, inquests and Board assurance
Identify when to use different learning response methods including PSII, AAR, swarm huddles, MDT reviews, thematic reviews and local learning responses
Apply human factors and systems thinking to maternity incidents including delayed escalation, fetal monitoring concerns, triage, maternal deterioration, neonatal transfer, documentation and communication failures
Improve the quality, consistency and clarity of maternity learning response reports
Develop safety actions that address underlying system issues and can be tested for impact
Review maternity PSIRF training, competency frameworks, protected time and oversight arrangements
Strengthen psychological safety, just culture and staff support while maintaining transparency and accountability to women and families
Take practical steps to ensure learning from maternity patient safety incidents leads to sustained improvement in care
Network with colleagues who are working to improve patient safety, learning and governance in maternity services
Learn from outstanding practice in maternity patient safety incident response
Reflect on how learning from incidents can be embedded in practice and shared across teams
Develop your skills in applying PSIRF principles to improve maternity care
Understand how to support staff, women and families following patient safety incidents
Ensure you are up to date with the latest national developments and learning
Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes