2019 Programme

2 - 3 July 2019
Manchester Central

Download the programme here

Patient Safety Congress Draft Programme
Pushing boundaries; spreading knowledge; transforming practice

This programme is a living document which serves as an indication of the final programme content, therefore details will change.

Day 1 – Tuesday 2 July 2019


Registration opens

09:00 – 09:15

Chair’s welcome and opening remarks

  • Set the scene for the Congress with an up to date overview of patient safety
  • Understand where we have come from and where we need to go next to improve safety
  • How you can make the most of the following two days to improve patient outcomes in your own organisation

Shaun Lintern, Patient Safety Congress Chair

09:15 – 10:00

Nicholas’ story: Listening to patients and families is vital to deliver safe care

  • Hear about Nicholas’ story from his mother, Sue
  • Deliver safe care: How to work with families as experts in the complex needs of vulnerable patients
  • Learn from the work of Nicholas’ family to improve your own practice

Sue Jones, Patient Representative

Panel discussion

Dr Pauline Heslop, Programme Lead, Learning Disabilities Mortality Review (LeDeR) Programme, Bristol University
Sue Jones, Patient Representative
Representative, NHS England

10:00 – 10:45

The long-term strategy for patient safety: What does it mean for you?

  • Understand the key elements of the national patient safety strategy
  • Learn about the detailed plans that underpin each element
  • How your work will change as a result

Dr Aidan Fowler, National Director of Patient Safety

Panel discussion

Professor the Lord Darzi of Denham, Paul Hamlyn Chair of Surgery, Imperial College London
Dame Marianne Griffiths, Chief Executive, Western Sussex Hospitals FT
Professor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University
Scott Morrish, Patient Representative
Professor Anne Marie Rafferty, President, Royal College of Nursing

10:50 - 11:20

Morning break in exhibition hall


Using technology and innovation to improve safety
Chair: Mike Durkin, Centre for Health Policy, Imperial College London

Mastering governance and regulation in a changing landscape (day 1)
Chair: Dr Elaine Maxwell, Clinical Adviser, NIHR Dissemination Centre

Learning from other safety critical industries
Chair: Jonathan Hazan, Chairman, Patient Safety Learning

Supporting your workforce to deliver good patient care
Chair: Susanna Stanford, Patient Speaker


The deteriorating patient in a non-acute setting

  • The national perspective on the deteriorating patient
  • Understand the latest from the Patient Safety Collaboratives work on deteriorating patients in community and non-acute settings
  • Hear about the latest tools to help in non-acute settings

The National Patient Safety Collaboratives Programme

Ensuring safe staffing levels

  • Interpret the latest policy and evidence on safe staffing levels
  • See how other nations have adopted safe staffing policies
  • Understand safe staffing issues in your organisation to prevent avoidable harm

Dr Rhid Dowdle, Chair, RCP working party on safe medical staffing Professor Anne Marie Rafferty, President, Royal College of Nursing
Angela Reed, Senior Professional Officer, NIPEC

The Costa Concordia case: What can healthcare learn?

  • Learn from risk and safety management principles used at sea
  • Learn how to bring a team together to perform critical operations
  • Understand the role of training and development in team interaction and learning

Dr Nippin Anand, Principal Specialist in safety management systems and human factors

Spreading best practice governance across independent hospitals

  • Identify the areas for improvement highlighted by the CQC
  • Understand the scope and role of the ‘Consultant Oversight Framework’
  • Make improvements in your own work based on best practice

Dr Howard Freeman, Medical Director, Independent Healthcare Providers Network
Matt James, Chief Executive, Private Healthcare Information Network
Professor Sir Bruce Keogh, Lead, Consultant Oversight Framework
David Rowland, Director, Centre for Health and the Public Interest

12:10 – 12:15

Time to move between sessions


The impact of patient safety on medical costs

Session reserved for Datix

Getting end of life care right

  • The typical pitfalls with end of life care decisions
  • The legal requirements and responsibilities for clinicians and organisations
  • Sharing patients’ end of life care decisions across organisational boundaries within integrated care systems
  • The importance of patient and family involvement

Dr Chris Farnham, Consultant in Palliative Medicine, Bart’s Health Trust

Kate Masters, Patient Representative

Merry Varney, Partner, Leigh Day

How to make just culture work

  • Hear from Dr Clare Holt, a former air traffic controller about how just culture worked in NATS when she was involved in an incident
  • Learn how the RAF learns from mistakes
  • Based on the work of Pennine Care, consider how to truly change culture in healthcare

Dr Clare Holt, Former Air Traffic Controller

Air Commodore Paul Godfrey

Matt Walsh, Patient Safety Lead, Pennine Care FT

Civility saves lives

  • Hear first-hand how incivility, bullying and harassment causes harm
  • The evidence to make the case for civility in healthcare
  • How to change your own behaviour, and those around you, to achieve a safer team

Jono Broad,​ Patient Representative

Chris Turner, Consultant in Emergency Medicine, University Hospitals Coventry and Warwickshire Trust

Suzette Woodward, Sign up to Safety

13:05 - 14:05

Networking lunch break


Innovations in wound care

  • Learn about the work of the National Wound Care Strategy Programme
  • Understand the latest clinical evidence on best practice
  • Balance safety, efficacy and cost effectiveness with clinical assessment

To err is human: Using tech to support the human in all of us in reducing IV medication errors

  • Explore the latest data on IV medication error
  • Debate the pros and cons of drug error reduction software
  • Address the practical issues to ensure safe roll out and effective use of the software

Professor Rachel Elliott, Professor of Health Economics, Manchester University
Paul Lee, Medical Devices Training Manager, Swansea Bay University Health Board, Morriston Hospital
Catherine Maddock, Pain Nurse Lead, Hampshire Hospitals FT

Patient safety in unsafe environments

  • Understand the unique challenges in healthcare in a prison environment
  • Learn about the P.R.O.T.E.C.T. project and how it enables a learning culture
  • Translate the learning from the project into your own organisation

Dr Sarah Bromley, National Medical Director Health in Justice, Care UK

Recruitment and retention: Solutions

  • Hear the latest on how to ensure a safe level of staffing
  • Successful ways to improve your retention rates
  • Translate best practice to improve your own retention rates

Mark Cox, Clinical Services Manager, Causeway Hospital Coleraine

Alison Lynch, Chief Nurse & Director of Quality Governance, Stockport FT

Professor Mark Radford, Director of Nursing Improvement, NHS Improvement

14:55 - 15:00

Time to move between sessions


Improving care for the deteriorating patient

  • Understand the latest developments in early warning scores
  • The role of NEWS in recognising sepsis
  • Understand effective monitoring of deteriorating patients
  • Innovations available to recognise and respond to deteriorating patients

Katie Dutton, ​Student nurse and patient speaker

Dr Matt Inada Kim, National Clinical Lead for Deterioration

John Welch, President, International Society for Rapid Response Systems

Implementing the new medical examiner service
  • Hear about existing medical examiner work in England and Wales
  • Overcome barriers to implementation with leaders in the field
  • Learn about the next steps at a local and national level
Dr Alan Fletcher, National Medical Examiner
Kevin Lewis, Head of Registration & Coronial Services, Leicester City Council
Jason Shannon, Senior Responsible Officer for Medical Examiner Implementation in Wales

How other countries respond to patient safety incidents

  • Learn about patient safety reporting in Queensland
  • How national quality indicators support patient safety in the Netherlands
  • Understand how elements of this practice could be adopted in your own organisation

Jan Maarten van den Berg, Dutch Health & Youth Care Inspectorate

Dr John Wakefield, Deputy Director-General Clinical Excellence Queensland, Queensland Health

Respect protects: Improving professionalism to improve patient safety

  • The patient safety rationale for improving professional behaviours
  • How organisations should engage to support the Professional Behaviours and Patient Safety programme
  • A taster of the training: how to adapt your own behaviour

GMC Regional Liaison Service Representative and doctor engaged in this work

15:50 - 16:20

Afternoon break

16:20 - 17:00

The James Reason Lecture: Patients First: Why it is not that simple

  • Fatigue is dangerous for staff and patients, is enough being done to prevent it?
  • Understand the responsibilities trusts have to protect their staff and patients
  • Practical ways to overcome tiredness and ensure you and your team are getting enough rest

Dr Michael Farquhar, Consultant, Paediatric Sleep Medicine, Guy’s and St Thomas’ FT


Networking reception in exhibition hall

Day 2 – Wednesday 3 July 2019

09:00 - 09:10

Chair’s welcome and opening remarks

  • Reflect on the key learning points from yesterday’s sessions
  • Look ahead to today’s topics
  • Find out the winner of the Patient Safety Congress poster competition

Shaun Lintern, Patient Safety Congress Chair

09:10 – 09:45

The golden thread: Making the safest healthcare system in the world

The Rt Hon Matt Hancock MP, Secretary of State for Health and Social Care (TBC)

09:45 – 10:20

Creating the right communication culture to improve safety

  • Understand new, research-based insights into safety communication
  • View short video clips that highlight the social complexity of such communication
  • Take part in interactive audience participation and discussion of cases
  • Solutions and techniques that emphasise contextual dynamics and group/team reflexivity

Professor Trish Greenhalgh, Co-Director, Interdisciplinary Research in Health Sciences, University of Oxford

Professor Rick Iedema, Director, Centre for Team Based Practice & Learning in Health Care, King's College London

10:20 – 10:50

Morning break in exhibition hall


Putting Human Factors theory into action

In association with BD

Chair: Steve Shorrock, Chartered ergonomist & human factors specialist

Enabling a learning culture

Chairs: Mike Durkin, Centre for Health Policy, Imperial College London; Susanna Stanford, Patient Speaker

Mastering governance and regulation in a changing landscape (day 2)

Chair: Dr Elaine Maxwell, Clinical Adviser, NIHR Dissemination Centre

Prioritising safety for vulnerable people

Chair: Rebecca Thomas, Correspondent, HSJ

The deteriorating patient

NOrF Annual Conference



System design and Human Factors - preventing errors in healthcare

  • The latest on human factors and solutions to counter human error
  • How errors in healthcare led to innovative solutions
  • How you can implement practical changes

Dr Maryanne Mariyaselvam, Clinical Research Fellow, Queen Elizabeth Hospital, Kings Lynn


Human Factors stream in association with BD

Creating a safe culture for patients

  • Learn about international safety culture work and how to scale research
  • How to enact evidence-based culture improvement     
  • Vision for the future: Leveraging new technologies to create safer culture for patients

Mike Durkin, Centre for Health Policy, Imperial College London
Kelsey Flott, Manager, Imperial PSTRC
Erik Mayer, Theme Lead, Imperial PSTRC

Training to achieve a safe maternity service

  • What the long term plan means for maternity safety
  • Learn how high quality training can save lives
  • Hear how one hospital has transformed maternity safety

Dr. Edward Prosser-Snelling

Consultant Obstetrician and Gynaecologist, Norfolk and Norwich University Hospital FT

Dr. Manjula Samyraju, Consultant Obstetrician & Gynaecologist, North West Anglia FT

James Titcombe, Patient Representative

Sascha Wells, Maternity Improvement Adviser, NHS Improvement 

Reducing restrictive practices and improving safety on inpatient wards

  • Explore the national work around reducing restrictive practices
  • Hear about tools to reduce restraint, seclusion and rapid tranquilisation
  • Understand the impact for patients and families

Tom Ayers, Senior Associate Director, National Collaborating Centre for Mental Health (NCCMH)

Melanie Leahy, Patient Representative



Reducing avoidable harm for patients with physical deterioration
  • Hear about current and future national work on the deteriorating patient
  • Digital systems and innovations to join hospitals and community with real time data
  • Learn what smart wireless monitoring can do
  • The critical importance of the human component
Dr Matt Inada Kim, National Clinical Lead for Deterioration
John Welch, President, International Society for Rapid Response Systems
Chairs: Tracey Moore and Liz Staveacre, NOrF Board

NOrF Annual Conference


11:35 – 11:40

Time to move between sessions


What healthcare can learn from aviation

  • Deepen your understanding of human factors and their influence on safety
  • Learn what aviation does to counteract human factors and how it applies to the NHS


Human Factors stream in association with BD

How to enable people to speak up
  • Identify the skills required by staff and patients to feel able to speak up
  • Learn how to develop the skills to challenge unsafe behaviours and situations
  • Examples of where the development of skills has positively impacted safety

Learning lessons from serious incidents

  • Review the latest data on the investigation of never events and serious incidents
  • How the new patient safety incident investigation framework will make a difference
  • Equip yourself to learn from incidents

Improving community care for patients with learning disabilities

  • Learn about national work to improve services to enable people to live in the community
  • Hear about the support available
  • Understand the impact for patients and families

Representative, NHS England (invited)

Dylan Harrison, Patient Representative

Rob Webster, Chief Executive, South West Yorkshire Partnership FT (invited)

Quality metrics and data analysis for rapid response and patient safety
  • Understand the latest consensus on RRS from experts and patient representatives
  • The use of electronic healthcare records and real time dashboards to enhance patient safety
  • Evaluate the function of rapid response systems in QI, improve safety and reduce avoidable harm

Dr David Brealey, Consultant, University College London Hospitals FT

Dr Chris Subbe, Consultant in Acute, Respiratory and Intensive Care Medicine, Ysbyty Gwynedd


Chairs: Chris Hancock and Sarah Quinton, NOrF Board

NOrF Annual Conference


12:25 – 13:25

Networking lunch break


Leadership and implementation: How we can really prevent never events
  • The latest information on never events and why safety alerts are not successfully implemented
  • Alert implementation as a window into organisational safety and leadership culture
  • Hear real examples from trusts who adopted learning from a never event
Professor Ted Baker, Chief Inspector of Hospitals, CQC
Dr Frances Healey, Deputy Director of Patient Safety (Insight), NHS Improvement
Dr Timothy Ho, Medical Director, Frimley Health FT


Human Factors stream in association with BD

How to learn from, and spread, excellence

  • Hear about the work of Learning from Excellence and Safety II to create new opportunities for learning
  • The science of spread: how to expand and scale up excellence
  • See the evidence of impact via specific case studies including COPD discharge bundle

Jono Broad, Patient Representative
Adrian Plunkett, Learning from Excellence

Embedding QI culture across an entire trust

  • How one trust improved outcomes and cut costs with a QI programme
  • Understand the benefits of a flattened hierarchy
  • Practical advice on how to implement similar practices in your own organisation

Ensuring safe care for older people living with frailty

  • How to ensure our systems are fit for caring for an ageing population
  • Discuss how communit y rapid response teams could improve care for frail and elderly people at home
  • How Hull transform ed admission s, allowing patients to return home with support

Petrina Kaye, Rapid Response Team Lead and Michelle Pilkington, Specialist Dementia Nurse, Cambridgeshire Community Services Trust​

Professor David Oliver, Consultant in geriatrics and acute general medicine, Royal Berkshire FT

Dr Kirsten Richards, Consultant in the Department of Medical Elderly, Hull University Teaching Hospitals Trust

The role of outreach in end of life care
  • Bringing clinical and communication skills to the dying patient and their family
  • Help staff become aware of, and recognise end of life in the acute care sector
Professor Maureen Coombs, Professor in Clinical Nursing, University of Plymouth
Rapid Response Systems: a Cochrane review update
  • Discuss the systematic review findings and the included studies
Dr Jennifer McGaughey, Senior Lecturer, Queen’s University Belfast
Chairs: Alison Dinning, Emma Lynch and Natalie Pattison, NOrF Board


NOrF Annual Conference


14:10 – 14:40

Afternoon break in exhibition hall


Human Factors: Quickfire learning

  • Using a quickfire style of presenting, hear examples of best practice
  • Discover how innovative and award-winning teams have changed the way we approach human factors
  • Make use of question time to consider how you could implement similar innovations in your own work

Human Factors stream in association with BD

Avoiding blame to move forward

  • Understand the analysis of cases as an expert witness and what this tells us about blame
  • Hear from Susanna on how she worked with individuals and a specialism to move forward and ensure learning from her experience
  • Improvement in complex systems; creating a MatNeo learning system

Dr David Bogod, Consultant Anaesthetist, Nottingham University Hospitals Trust
Susanna Stanford, Patient Speaker


Maintaining safety in an integrated care system

  • Discuss how clear lines of accountability can be maintained in integrated care systems
  • Identify the key challenges to safety in integrated systems
  • Agree solutions to the challenges with those at the forefront of the system change

Reducing pressure ulcers

  • How we can reduce the number of pressure ulcers in patients in all health and care settings
  • Interventions available to prevent and treat pressure ulcers
  • How to change your own practice to treat, and ultimately prevent, pressure ulcer occurrence

Best of the abstracts from the critical care outreach and rapid response teams innovative and safety-driven work for the deteriorating patient

Chairs: Lesley Durham, Carmel Gordon-Dack and Liz Staveacre, NOrF Board


NOrF Annual Conference


15:25 – 15:30

Time to move between sessions

15:30 – 15:55

A vision for the nursing, midwifery and care professions 

  • The critical role of the professions in delivering the Long Term Plan 
  • The next generation: training, recruiting and retaining our nursing, midwifery and care workforce 
  • #teamCNO – mobilising the full diversity of the professions to improve patient care and the health of our communities

Ruth May, Chief Nursing Officer for England

15:55 -16:50

Exploring blame: How can the NHS balance system failure vs. individual error?

  • Hear from David Sellu, a former surgeon who was wrongly convicted of gross negligence manslaughter
  • The legal factors for practitioners working in acute setting with deteriorating patients across teams
  • How healthcare needs to transform to avoid a blame culture
  • Join a discussion on the wider issues of just culture and regulation in healthcare

David Sellu, Former Surgeon
Andrea Sutcliffe, Chief Executive and Registrar, NMC
James Titcombe, Patient Representative
Jenny Vaughan, Consultant Neurologist and medical law campaigner
Professor Sir Norman Williams, Chairman, National Clinical Improvement Programme


Chair’s closing remarks
Shaun Lintern, Patient Safety Congress Chair


Please take time to give your feedback via the app


Close of conference

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