Learning From Adverse Events in Maternity Services

Improving the way healthcare organisations respond to and learn from adverse events in maternity services.

Please click on a course on the table below to book your place.
Start Time Name Details Location Price
September 12, 2022 - 9:30 am

Learning From Adverse Events in Maternity Services – 12 and 13 September 2022

£250.00 Add to cart

Please ensure that you have read and understood our terms and conditions before booking.


The Need For Training

The way in which NHS organisations investigate and learn following adverse events has been highlighted as a cause for concern repeatedly in numerous recent reports and inquires (Each Baby Counts, 2018, 2020; CQC, 2020).

This course has been developed with leading experts from NHS Improvement (NHSI) and NHS Resolution (NHSR) to provide delegates with crucial training in areas where a need for improvement has been repeatedly identified, including investigation methodology and approach, family engagement, treating staff fairly in line with ‘just culture’ principles, report writing and developing effective improvement actions.

Aims of the Course

To give attendees the knowledge and skills they need in order to:

  • Understand all current national notification and reporting requirements.
  • To understand the principles of good incident investigation, including human factors, systems thinking, methodology and tools.
  • Be confident and skilled in how to engage and support families throughout investigative processes (sensitively and compassionately).
  • Understand the principles of a ‘just culture’ and how to support staff following adverse events.
  • Write good, clear and effective investigation reports.
  • Develop effective and evidenced based improvement actions.
Relevant for

All members of the maternity team including midwives, obstetricians, risk managers, maternity safety champions, bereavement support staff and all staff involved in quality/safety improvement.

This course is of benefit to all maternity professionals wishing to learn more about investigative processes and safety improvement.

Course Content

Using a combination of formal talks, workshops, and interactive discussions the following topics are covered:

  • An overview of the national requirements, including reporting, notifications and internal/external processes and an understanding of WHY they are all there.
  • Practical training on how to support a ‘just culture’, including tools and key principles and behaviours.
  • How to sensitively and compassionately engage with families throughout investigation processes (in line with best practice model).
  • The 72-hour review process, including initial debrief, supporting staff, gathering information and notification/reporting requirements.
  • Hearing directly from an NHS organisation about their improvement journey, how progress was achieved and the barriers and challenges.
  • Practical workshop based on a real-life scenario (anonymised) so that delegates can practice and use the skills and knowledge gained during the course in practice.
  • Mr Michael Magro
    Course Director
  • Emeritus Professor James Walker
    Course Advisor
  • Sascha Wells-Munro, OBE
    Course Director
  • james-titcombe
    James Titcombe, OBE
    Course Director