• Reflections from several London trusts on their service transformations and improvements following implementation of ‘learning from deaths national strategy’
• Insights from how the new serious incident framework will improve patient safety and support staff involved in serious incidents.
• Expert panel debate with leading experts from the NHS, Trusts and legal profession sharing their experiences of inquests and learning.
• Launch of new learning materials to support staff prepare for coroners court.

Facilitated round table discussion, focusing on:

1. Learning from Serious Incidents – working with patients to shape safer services
2. Supporting staff through difficult serious incidents and inquests
3. Shift in investigations from ‘who is responsible?’ to ‘what is responsible?’
4. Using legal mediation to improve resolution for families and NHS providers
5. Coronial insights on preparing and undertaking inquests to improve the learning

Programme:

Learning from deaths – trust insights Register here

Registration and refreshments

9am

Chair’s welcome and housekeeping

Justine Sharpe, Safety and Learning Lead (London region), NHS Resolution

9.05am

Local and national perspective on safety improvements

Dame Eileen Sills, Chief Nurse and Deputy Chief Executive, Guys and St Thomas’ NHS Foundation Trust

Denise Chaffer, Director Safety and Learning, NHS Resolution

9.30am

Reflections and realities of mortality surveillance a trust’s experience

David Wood, Consultant Physician and Clinical Toxicologist, Trust Lead for Mortality Surveillance and Review, Guys and St Thomas’ NHS Foundation Trust

9.55am

How the new serious incident framework serves patient and staff safety

Martin Machray, Regional Director, NHS England and Improvement

10.15am

Supporting staff through Coroner’s Court - the cross examination process

Martin Drage, Consultant Transplant Surgeon, Guys and St Thomas’ NHS Foundation Trust

Justine Sharpe, Safety and Learning Lead, NHS Resolution

10.35am

Panel discussion –

supporting families and staff through serious incidents and inquests

Chair: Michele Golden, Deputy Director, Safety and Learning, NHS Resolution

• Nadia Persaud, Senior Coroner, East London
• Simon Lindsay, Partner, Bevan Brittan
• David Wood, Consultant Physician, Guys and St Thomas’ NHS Foundation Trust
• Keith Soper, Service Director, Oxleas NHS Foundation Trust
• Martin Machray, Regional Safety Director, NHS Improvement

11.30am

Refreshments

Sharing multiple perspectives on risk and system based learning to provide safer services

Focussed facilitated discussions in small groups where delegates will rotate every 15 minutes around each of the five tables to enable greater interaction and shared networked learning.

11.45 – 1.00

15 min/ sessions

Learning from Serious Incidents – working with patients to shape safer services

Table 1

Led by: Royal Free London NHS Foundation Trust

Dr Hester Wain, Deputy Director of Patient Safety and Risk, Royal Free London NHS Foundation Trust

Brady Pohle, Head of Legal Services,Royal Free London NHS Foundation Trust

Supporting staff through difficult serious incidents and inquests

Table 2

Led by: Oxleas NHS Foundation Trust

Dr Keith Soper, Director, Forensic and Prison Services

Shift in investigations from ‘who is responsible?’ to ‘what is responsible?’

Table 3

Led by: Dr Martin Baggley, Locum doctor

Using legal mediation to improve resolution for families and NHS providers

Table 4

Led by: Bevan Brittan

Julie Charlton, Partner, Bevan Brittan

Sarah Pearson, Head of Legal Services Royal Berkshire

Coronial insights on preparing and undertaking inquests to improve the learning

Table 5

Led by: Eastern District of London

Nadia Persaud, Senior Coroner, East London

Delegates will rotate on each table every 15 minutes.

1.001.10

Reflections and close

Joanne Easterbrook, Senior Partner, Bevan Brittan

1.10 – 1.30

Light refreshment to continue networking and capture feedback