The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care

The objective is for medical examiners to independently scrutinise all non-coronial deaths across England and Wales

NHS England

Care Quality Commission (CQC) inspections have shown good progress is being made by some NHS hospital trusts to implement national guidance on learning from deaths. However, failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed… the amount of progress made to date varies between trusts and CQC analysis suggests that some organisations have found it harder than others to make the changes needed

Care Quality Commission

The conference will also update delegates on the New National Patient Safety Incident Response Framework which was published on 16th August 2022 and the implications for serious incident investigation and learning from deaths.

“A key part of the preparation for PSIRF will be a review of your current systems and processes against the new patient safety incident response standards. This will determine where effort should be maintained and where adaptations are required…Organisations are also required to develop and publish their own patient safety incident response policy and plan. Developing this plan will include establishing your local patient safety incident profile and reviewing your existing improvement work. This will help inform how you plan to maximise opportunities for learning and improvement in the areas where patients will benefit the most.”

NHS England August 2022

“The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS.”

NHS England August 2022

Attendance at this conference will support you to:

  • Network with colleagues who are working to improve practice in the investigation and learning from deaths
  • Learning from the Mortality Case Review
  • Reflect on the lived experience of a carer
  • Learning from deaths during Covid-19Learn from working examples of mortality governance and develop the role of mortality audits, internal inspection and mortality reviews to answer the question “did a problem in care contribute to the death?”
  • Implement the new Patient Safety Incident Response Framework and improve learning from serious incidents
  • Understand national developments and national reporting requirements
  • Learn from best practice in the investigation of deaths
  • Identification and reporting of deaths and the role of the Medical Examiner – including extending this role to all non-coronial deaths
  • Improving your processes and skills in mortality review and mortality governance
  • Reflect on how you improving involvement of families and carers
  • Understand the decision to investigate, and the appropriate level of investigation
  • Improving your skills in serious Incident Investigation: and understanding the implications of the New Patient Safety Incident Response Framework
  • Explore how a human factors can support learning from deaths
  • Effectively support staff when a death occurs including supporting staff through coroner inquests and serious incident investigations
  • Self assess your learning from deaths process and ensure investigations lead to change
  • 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

If you would like to attend this event please contact the organiser’s website