“We all make mistakes. We should strive to avoid them, of course, but the fact of a mistake isn’t the biggest problem. It’show we respond to them and how we learn from them, that’s what’s most important. And we must never let our fear ofthe consequences, stop us from doing the right thing.”Secretary of State for Health and Social Care Matt Hancock February 2019“We want the NHS to be the safest healthcare system in the world….We also propose a focus on three principlesthat should underpin implementation of the strategy: a just culture, openness and transparency and continuousimprovement.” NHS Improvement December 2018“We know there are problems, for example, with how incidents are investigated and learned from. In our recentengagement to find out how we can improve the Serious Incident framework, people told us they were concerned about:providers’ lack of capability and capacity to carry out good quality investigations; the tendency to use investigation forthe wrong purposes; the generally poor approach to patient and family involvement; and the fact that actions to reducerisks after the completion of an investigation are too often ineffective. We know from the Care Quality Commission’s(CQC’s) review of how the NHS responds to and learns from the care provided to patients who die that too oftenproblems with care are not identified and the bereaved, who may have concerns, are not sufficiently supported.”NHS Improvement December 2018This national conference looks at the practicalities of Serious Incident Investigation and Learning. The event will look atthe revised Serious Incident Framework which is currently post consultation and due for publication in Spring 2019, andthe implications for serious incident investigation. The conference will update delegates on the National Learning fromDeaths guidance and implementation in practice. There will be a focus on learning from serious incidents, ensuring theinvestigation findings lead to change and improvement.This conference will enable you to:• Network with colleagues who are working to improve the investigation of serious incidents• Learn from outstanding practice in the development of serious incident investigation and mortality review• Reflect on the perspectives of bereaved families and carers and understand how you can engage them and recognisetheir insights as a vital source of learning in line with the National Guidance• Update your knowledge with national developments including forthcoming revised 2019 Serious Incident Framework• Reflect on the development of mortality governance within your organization• Understand how to work with staff to ensure a focus on learning and continuous improvement• Develop your skills in Serious Incident Investigation: applying the serious incident framework and using skilled analysis tomove the focus of investigation from acts or omissions of staff, to identifying the underlying causes of the incident• Identify key strategies for improving investigation of serious incidents• Gain CPD accreditation points contributing to professional development and revalidation evidence