This provides delegates, and other interested parties, with access to resources related to Safety and Learning events. The materials available here for several months, but will be updated and replaced with the most recent resources in due course.
Collaboration for safer and sustainable maternity care
Date held: 25 January 2024
This was a joint NHS Resolution and Kennedy’s event aimed at Obstetric and Midwifery Leads, and Heads of Legal Services in the South East of England and London.
Presentation slides
- NHS Resolution and Kennedy’s – Maternity Claims Data and Early Notification Case Themes
- Equal Lives Equal Start
- Digital technology at Portsmouth Hospital University NHS Trust
- Community emergency skills training for midwives and paramedics – Surrey Heartlands
- A New Era of Obstetric Emergencies Through Digital Transformation
NHS Resolution: An introduction to our corporate strategy and our work to improve the response to harm, with a focus on the maternity sector
Date held: 12th October 2023
NHS Resolution’s Early Notification team describe our initiatives and resources to improve the response to harm and elements of our work in maternity, such as the Maternity Incentive Scheme, Early Notification Scheme, how we support the family experience and the work of the Maternity Voices Advisory Group.
Contributors
Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution
Sangita Bodalia CMgr MCMI, Head of Early Notification (Legal), NHS Resolution
Jayne Poole RM, Safety and Learning Lead (Early Notification), NHS Resolution
Elizabeth Pells RM, Early Notification Family Liaison and Mediation Lead, NHS Resolution
Resources
Sepsis in Primary Care virtual forum
Date held: 23 March 2023
NHS Resolution’s Safety and Learning team are hosted a virtual forum on sepsis in primary care. They shared our data and learning insights on sepsis claims to support improvements in safety and experience.
Contributors
Dr Ron Daniels – Founder and CEO, The Sepsis Trust
Majid Hassan – Partner, Capsticks Solicitors LLP
Ellen Nicholson – Safety and Learning Lead for General Practice, NHS Resolution
Nicole Mottolini – Clinical Fellow, NHS Resolution
Chair – Naomi Assame – Head of Safety and Learning, NHS Resolution
Resources
Emergency Department virtual forum
Date held: Monday 30 May 2022
NHS Resolution’s Safety and Learning team hosted a virtual forum to share the key themes from our latest reports which led to claims in the Emergency Department in England between 2014 and 2018. Recognising the unique challenges and diversity of clinical presentations seen in Emergency Departments, our forum focuses on: high value and fatalities; missed fractures; falls and pressure ulcers. Clinical themes extracted from our claims data can provide a unique insight to enhance safety, patient experience and strengthen evidence to improve and redesign practices. Claim numbers for emergency medicine have risen in recent years and we have identified areas to improve service. The purpose of the forum was to share insight and promote spread of experiential learning in collaboration with the Royal Colleges of Emergency Medicine and Nursing to inform best service and practice pathways.
Contributors
Justine Sharpe, Safety and Learning Lead (London)
Dr Denise Chaffer, Director of Safety and Learning
Tim Shurlock, Safety and Learning Lead (South)
Bev Hunt, Safety and Learning Lead (Mediation)
Panel discussion
Chair: Dr Alex Crowe, Deputy Director for Incentive Schemes and Academic Partnerships
Bev Hunt, Safety and Learning Lead (Mediation)
Katherine Henderson, President of Royal College of Emergency Medicine
Resources:
Watch the recording of this virtual forum here: Learning from Emergency Department (ED) claims virtual forum – NHS Resolution
Patient Safety Incident Response Framework (PSIRF) virtual forum
Date held: Thursday 17th March 2022
NHS Resolution’s Safety and Learning team, in partnership with NHS England and Improvement’s (NHSEI) safety team hosted a virtual forum to support members prepare for the implementation phase of the Patient Safety Incident Response Framework (PSIRF). We heard about the experiences and challenges from an early implementer pilot of PSIRF as well as a Coronial and legal perspective. The purpose of the forum was to spread insight and experiential learning across health providers to support preparations for PSIRF.
Patient Safety Incident Response Framework (PSIRF) programme
- Preparation guidance to support planning for PSIRF.
- Managing expectation of the Coroner’s Office – documentation needed to support PSIRF
- Reflect and share experiences and challenges as an early adopter site within the national PSIRF pilot
- Legal insights
- Signpost to support resources to aid patient safety incident management
Contributors
Vicky Aldred, Deputy Director of Patient Safety and Patient Safety Specialist – NHSEI London
Jess Peck, Clinical Quality Manager – NHSEI London
Derek Winter, Deputy Chief Coroner of England and Wales and HM Senior Coroner for the City of Sunderland
Helen Woolford, Head of Quality Improvement & Learning – London Ambulance Service (early adopter in PSIRF Pilot)
Jo Lloyd, Senior Partner – Bevan Brittan
Helen Woolford, Head of Quality Improvement & Learning – London Ambulance Service (early adopter in PSIRF Pilot)
Justine Sharpe, Safety and Learning Lead (London) – NHS Resolution
Resources
Maternity Conference: Collaborate to improve maternity care: respond to, learn from and prevent harm
Date held: 28 November 2022
We held a face-to-face national maternity conference, Collaborate to improve maternity care: respond to, learn from and prevent harm, at the Royal College of Physicians as part of NHS Resolution’s maternity campaign 2022/25. The following materials are resources shared by our speakers, exhibitors and NHS Resolution staff.
Programme and speaker biographies
Collaborate to improve maternity care – final programme
Slides from the day
- Setting the scene, headlines for 2022 from our work in maternity
- Current challenges in staffing maternity units
- Maternity eLearning case story modules
- Learning from claims related to neonatal GBS
- Protecting the mental health of NHS staff
- Best practice response and working with families
- Working with families at WUTH
- The evolution of the Early Notification Scheme
- Supporting Staff After Incidents
Recordings from the day
We are pleased that the majority of the speakers were recorded. If you’d like to watch any of the talks back, please follow these links:
- Talks between 09:30-11:15 including Dr Denise Chaffer, Professor Tim Draycott and Dr Jo Mountfield.
- Talks between 11:45-12:45 including Annette Anderson, Lynn Tilley, Dr Rachel Walsh and Professor Neil Greenberg.
- Talks between 1:45-3:15 including Dr Dawn Benson, Dr Angela Kerrigan, Catherine Cumberlidge, Jyoti Sidhu, Sangita Bodalia, Marianne Rowntree, Dr Matt Julian and Dr Helen Halls.
- The Panel discussion – chaired by Rob Tobin (Partner, Kennedys)
Early Notification and Safety and Learning team resources
- The second report: The evolution of the Early Notification Scheme.
- The second report summary infographic
- The Early Notification Scheme case stories
- All our Safety and Learning team resources.
- Faculty of Learning – NHS Resolution
- Find out more about the Early Notification Scheme.
Exhibitor resources
Our Exhibitors have kindly provided the following useful resources for those that attended the conference.
The Royal College of Obstetricians and Gynaecologists
- Roles and responsibilities of the consultant providing acute care in obstetrics and gynaecology
- RCOG updates, guidance and position statements on safe staffing
- Guidance on the engagement of short-term locums in maternity care
- Certificate of Eligibility for short-term locums (CEL)
Peeps-HIE
Poster competition
NHS Resolution Poster Competition 2022 entries
Learning from Claims: Hospital Acquired Pressure Ulcers virtual forum
Date held: Thursday 14th October 2021
NHS Resolution’s Safety and Learning team shared our data and learning insights on hospital acquired pressure ulcer (HAPU) claims to support improvements in safety and experience. Working in partnership with a range of experts in the topic area to help spread best practice. Our claims insights highlighted common risk themes we have observed regionally as well as sharing solutions as to how some of the risks have been reduced by making systemic and systematic changes. The format was interactive and our experts are a combination of providers, commissioners, patient safety leads and policy makers.
Hospital Acquired Pressure Ulcers programme
- Value and volume of HAPU claims for NHS providers.
- National and regional initiatives.
- Case stories – highlighting common learning themes.
Contributors
Jacquie Fletcher, Senior Clinical Advisor – Stop the Pressure Programme/National Wound Strategy, NHS England and NHS Improvement
Glenn Smith, Advanced Nurse Practitioner, St Helens Medical Centre, Isle of Wight.
Dr Fania Pagnamenta, Clinical Academic Nurse Consultant, Newcastle upon Tyne Hospitals NHS FT & Northumbria University
Beverley Hunt, Safety & Learning Mediation Lead, NHS Resolution
Resources
Learning from Claims: Missed Fractures virtual forum
Date held: Thursday 9th September 2021
NHS Resolution’s Safety and Learning team shared our data and learning insights on missed fractures claims to support improvements in safety and experience. Working in partnership with a range of experts in the topic area to help spread best practice. Our claims insights highlighted common risk themes observed regionally as well as sharing solutions as to how some of the risks have been reduced by making systemic and systematic changes. The format was interactive and our experts were a combination of providers, commissioners, patient safety leads and policy makers.
Programme
- Value and volume of falls claims for NHS providers in London and the South regions
- National and regional initiatives.
- Case stories – highlighting common learning themes.
Contributors
Dr Robin Evans, Consultant Radiologist
Dr Taj Hassan, Consultant in Emergency Medicine
Richard Evans, Chief Executive, Society of Radiographers
Tim Shurlock, Safety & Learning Lead, NHS Resolution
Resources
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