health & social care Training

Serious Incident Investigation and Reporting

health & social care Training

09:15 - 16:15

Tuesday 14 May 2019

Congress Centre, Central 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 published in spring 2019, 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:
  • 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)


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



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
  • Sharing a case example to give insight into the investigation approach
  • Discussing safety recommendations from the 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

*Programme subject to change

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.

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