health & social care Training

Serious Incident Investigation and Reporting

health & social care Training

09:15 - 16:15

Tuesday 12 March 2019

Central London, London

NHS patient safety investigations can have a lasting social and psychological impact on patients, families, carers and staff alike. The revised Serious Incident Framework, to be announced in late 2018, has been fuelled by recent efforts to improve investigation practice and better support those affected by incident and prevent repetition of harm. Additionally, with the establishment of the Healthcare Safety Investigation Branch (HSIB) the aim is to drive positive change across the system.

This interactive training course will provide you with applied examples of implementation of serious incident investigation practices as well as example of effective working with patient families, supporting staff post-incident and writing effective RCA reports.

This training will also provide practitioners with key updates on the serious incident investigation process and will ensure that the serious incident investigation process within your organisation is effectively able to investigate, communicate and then consequently learn from when things go wrong.

Learning Objectives:
  • Hear about key reforms to the Serious Incident Framework and its implications for all practitioners having to write serious incident investigation reports
  • Discover how you can provide effective post incident staff support
  • Learn how to be as open as possible with patient’s, families and carers in the incident investigation process
  • Hear key takeaways from an NHS Trust’s journey to improving their patient safety through incident investigation
  • Take away a plan on how to successfully implement effective incident investigation practices in your organisation


Chris Brougham, Director, VERITA


Melanie Ottewill, National Investigator, Healthcare Safety Investigations Branch

Paul Sams, Project Coordinator, Positive and Safe Care, Northumberland, Tyne and Wear NHS Foundation Trust

Sarah Pearson, Head of Legal Services, Risk & Patient Safety, Southern Health NHS Foundation Trust

Sue Cox, Governance and Quality Lead, Darent Valley Hospital

View the agenda and additional speakers




Chair’s Welcome and Clarification of Learning Objectives

Chris Brougham, Director, VERITA (CONFIRMED)


Serious Incident Framework and Reporting

  • Proving an update on Serious Incident Framework reforms and implementation
  • Understand how to effectively report on serious incidents and interpreting incident data correctly
  • Applying the ‘Duty of Candour’ with staff and patient families

Mike Durkin, Senior Advisor on Patient Safety Policy and Leadership at Institute of Global Health Innovation, Imperial College London (INVITED)


Effectively Communicating with Patients and Families During the Investigation Process

  • Understanding the critical importance of effectively communicating with families and carers throughout the incident investigation process
  • Facilitating open and transparent communications at every stage of the process with patients and their families
  • Making provisions to ensure advice and emotional support is provided to patients and their families
  • Establishing the position of family liaison officer to support bereaved families and ensure effective communication process

Peter Walsh, Chief Executive, Action against Medical Accidents (INVITED)


Morning Break


Effective Post-Incident Staff Support

  • Understanding your responsibilities, accountability process and avoiding a ‘blame’ culture
  • Ensuring immediate support is offered to staff following the incident
  • Implementing a system of ongoing support that includes stress management and counselling if required
  • Providing appropriate training for staff working with bereaved families
  • Effectively supporting staff in courts, hearings and tribunals

Paul Sams, Project Coordinator, Positive and Safe Care, Northumberland, Tyne and Wear NHS Foundation Trust (CONFIRMED)


Case Study: A Journey to Improving Safety through Effective Serious Incident Investigation Process

  • Understanding and implementing the investigation process and setting up the right practices
  • Improving organisational culture and practices to ensure openness and transparency
  • Ensuring that investigations are of a consistently high quality through staff training and process reviews
  • Learning from experience and improving procedures

Sarah Pearson, Head of Legal Services, Risk & Patient Safety, Southern Health NHS Foundation Trust (CONFIRMED)




Investigation Case Study: Implantation of Wrong Prostheses During Joint Replacement Surgery

  • Introduction to the Healthcare Safety Investigation Branch and its remit
  • Discussing background and sharing a case example and insight into investigation approach
  • Development of safety recommendations post-investigation
  • Question and answer session

Melanie Ottewill, National Investigator, Healthcare Safety Investigations Branch (CONFIRMED)


Workshop: A Guide to Writing RCA Reports

In this session, delegates will work with the trainer in small groups to refine their report writing strategies for multiple case studies

  • What does a good report look like?
  • Knowing your audience
  • Use of language and grammar
  • Medical terminology
  • Avoiding assumptions

Sue Cox, Governance and Quality Lead, Darent Valley Hospital (CONFIRMED)


Comfort Break


Workshop: Best Practice Approach to Investigation Process and Post-Investigation Action Plan

  • Using a well-structured methodology and analysis to identify key factors of serious incident
  • Develop an appropriate and effective interview strategy and plan
  • Incorporating human factors approach to investigations
  • Making recommendations following serious incident investigations
  • Enabling a step change in the way that serious incidents are investigated and managed
  • Creating an action plan that will reference how a shared learning will be implemented both in the specialty involved and across the wider organisation

Chris Brougham, Director, VERITA (CONFIRMED)


Feedback, Evaluation & Close

Chris Brougham, Director, VERITA

Chris is a Director at Verita, an organisations that carries out investigations and reviews in healthcare. Chris is a qualified mental health nurse and an experienced manager. She has previously worked as a Director of Nursing in a large mental health trust. She also worked at the National Patient Safety Agency working collaboratively across the whole health community to promote patient safety and improve investigations into serious incidents in the NHS.

She is an experienced investigator and has conducted some high-profile investigations over the years including mental health homicides, safeguarding reviews and investigations into the care and treatment of patients in acute hospitals.

She also heads up the Verita training programme and delivers training across the UK.

Melanie Ottewill, National Investigator, Healthcare Safety Investigations Branch

Melanie is a registered nurse and qualified social worker and have worked in both statutory and non-statutory settings.

She is currently working as a National Investigator with the Healthcare Safety Investigation Branch. Prior to this post, I worked in a large, acute teaching hospital for over 20 years in different clinical settings as well as posts such as the Head of Complaints and Head of Clinical Investigations.

Melanie is passionate about increasing the focus on Human Factors in incident investigations and ensuring meaningful engagement with patients and families who have experienced harm during their care.

Sue Cox, Governance and Quality Lead, Darent Valley Hospital

Sue Cox is a nurse and qualified from the trained at the Royal United in 1989! Her background is Cardiology and spent 20 years in various roles and Trusts caring from patients from day case Cardiology, to ITU and Rehabilitation

Between 2001 and 2007 She had x2 spells of work in New Zealand working in the private sector within cardiothoracic surgery.

On return to the UK she joined Darent Valley Hospital in Dartford as Cardiology Matron. After taking the lead for governance within the medical Directorate she became  a full time member of the governance team within the Trust in 2015. She leads the patient facing side of governance (complaints, PALS, and Investigations). As such she is often the person who makes first contact with patients and their families with regard to Duty of candour.

Sue has a Post Graduate Diploma in healthcare Ethics and an MSC in Advanced Practice (Cardiology) both from Kings college London. Her dissertation was a systematic review into the barriers that prevent nurses reporting medication errors.


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