Never say never again – how learning from errors and mortality review can improve clinical practice

17/10/2018 9:00 am @ This event has now passed

Event Details

The AHSN NENC in partnership with NHS Improvement, NHS England and NEQOS bring you an event to support improving the share and spread of learning from mortality reviews, clinical incidents and never event investigations for the regions Trusts.

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Learning From Deaths (LFD) and the South Tees Medical Examiner Service – Tony Roberts and Diane Monkhouse

Learning From Deaths (LFD) National Overview – Matt Fogarty

The Decision to Investigate – Andy Haynes

Making LeDeR Real – Judith Thompson

LeDeR Response to Annual Report 2018

Harm Events in the North Cumbria and North East – Ruth James

Why we need to learn for patients and staff – Bill Kirkup

Agenda

09:30   Registration and Refreshments
09:55 Welcome and Introduction

Mr. Tony Roberts

Patient Safety Collaborative Programme Lead

Academic Health Science Network for the North East and North Cumbria

10:00 Learning From Deaths (LFD) National Overview

Matt Fogarty

Deputy Director of Patient Safety (Policy and Strategy)

NHS Improvement

10:35 Learning From Deaths (LFD) and the South Tees Medical Examiner Service

Mr. Tony Roberts

Patient Safety Collaborative Programme Lead

Academic Health Science Network for the North East and North Cumbria

11:10 Refreshment Break
11:25 Learning Disability Mortality Review Programme (LeDeR): what we are learning from reviews

Judith Thompson

Network Manager & Assurance Lead

North East & Cumbria Learning Disability Network

 

Gill Findley

Director of Nursing

Durham Dales, Easington and Sedgefield CCG and North Durham CCG

 

Phil Hughes

Expert by Experience from Stop People Dying Too Young Group with Karen Hughes

11:55 The Decision to Investigate

Dr Andy Haynes

Executive Medical Director

Sherwood Forest Hospitals NHS Foundation Trust

12:25 Harm Events in the North Cumbria and North East

Ruth James

Safety Culture Collaborative Programme Lead

Academic Health Science Network for the North East and North Cumbria

12:55 Lunch and Networking
13:40

Sharing Learning. Reducing Harm

Workshop to explore:

  • How to improve the sharing of learning – both successes and failures – within and between organisations
  • How do we identify opportunities for cross organisation / system actions to reduce harm?
  • How do front line clinicians access learning that is relevant to their practice?
  • How do we give clinicians access to examples of effective interventions?
  • How do we make sure actions are effective and embedded?
15:00

Why we need to learn for patients and staff:

Identifying the underlying causes of systemic failure to determine how to avoid future tragedies

Dr Bill Kirkup’s analysis of the Morecambe Bay, Liverpool Community and Hillsborough investigations:

  • The underlying causes that lead environments to fail
  • Identify the warning signs to take action in your own organisation and nip problems in the bud

Prevent problems escalating to crisis point with early interventions

Dr Bill Kirkup CBE

Former Chair, Morecambe Bay Investigation

Member, Gosport Independent Panel

15:30 Final Comments
15:40 Close

The event will provide networking opportunities enabling you to talk to colleagues and to ask the ‘experts’.

NEQOS provides support to trusts across the North East and North Cumbria around mortality surveillance and assurance. The key components of this support are: the provision of quarterly monitoring information on mortality; ‘deep dives’ for individual trusts when they are mortality outliers; assistance in the implementation of national guidance on mortality review and investigation.

For further information please contact sarah.black@ahsn-nenc.org.uk