Venue: De Vere West One Conference Centre, London

This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look at the development of the New Patient Safety Incident Response Framework (previously know as the Serious Incident Framework) the scope of which was announced in July 2019, and the implications for serious incident investigation.

”While recognising the importance of learning from what goes well, identifying incidents, recognising the needs of those affected, undertaking meaningful analysis and responding to reduce the risk of recurrence remain essential to improving safety. Doing this well requires the right skills, systems, processes and behaviours throughout the healthcare system. The PSIRF will support the NHS to operate systems, underpinned by behaviours, decisions and actions, that assist learning and improvement, and allow organisations to examine incidents openly without fear of inappropriate sanction, support those affected and improve services”

NHS Improvement 2019

“Patient safety is about maximising the things that go right and minimising the things that go wrong…It is human to make mistakes so we, the NHS, need to continuously reduce the potential for error by learning and acting when things go wrong.”

The NHS Patient Safety Strategy July 2019

The conference will examine the development of a risk based response to incidents as outlined in the July 2019 NHS patient safety strategy “we think organisations should develop a patient safety incident review and investigation strategy to allow them to use a range of proportionate and effective learning responses to incidents. The proposal is to explore basing the selection of incidents for investigation on the opportunity they give for learning; and ensuring that providers allocate sufficient local resources to implement improvements that address investigation findings.”

The conference will also update delegates on the National Learning from Deaths guidance and implementation in practice including the new role of the Medical Examiner. There will be an extended focus on learning from serious incidents, ensuring the investigation findings lead to change and improvement.