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

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

Patient Safety Collaboratives

Implementing the new medical examiner service

  • Hear how medical examiners have already been improving patient safety
  • Overcome barriers to implementation with leaders in the field
  • Consider the next steps at a local and national level

New National Medical Examiner (TBC)

Jason Shannon, Senior Responsible Officer for Medical Examiner Implementation in Wales

Kevin Lewis, Chief Superintendent Registrar, Leicester City Council (invited)

Safety at sea: What can healthcare learn?

  • Understand the combination of technical and social dimensions of risk and safety
  • Learn from risk and safety management principles used at sea
  • Implement changes based on the maritime approach to safety

Nippin Anand, Principal Specialist in management systems and human factors

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

Hugh McCaughey, Chief Executive, South Eastern Health & Social Care Trust (invited)

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

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

Session reserved for BD

How to: Conduct effective root cause analysis

  • Understand the role of root cause analysis in finding out why errors happen
  • Get step-by-step advice on carrying out a root cause analysis
  • Examine a case study of effective root cause analysis to put your learning into context

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

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

Dr Matt Inada Kim, National Clinical Lead for Deterioration

John Welch, President, International Society for Rapid Response Systems

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

David Hare, Chief Executive, Independent Healthcare Providers Network

Professor Sir Bruce Keogh, Lead, Consultant Oversight Framework

David Rowland, Director, Centre for Health and the Public Interest

Dr Andrew Vallance-Owen, Chair, Private Healthcare Information Network

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

Looking after the team, looking after the patient

  • Analyse the latest figures on mental health disorders in the healthcare profession
  • Hear case studies of how the right support is vital in helping our frontline workforce to care effectively for patients
  • Consider what wellbeing support your trust offers and how it could be improved

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

Chair: Mike Durkin, Centre for Health Policy, Imperial College London

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

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 (invited)

Susanna Stanford, Patient Speaker

Patient Safety Collaboratives

Achieving progress on maternity safety

  • 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

Cllr Dr Jacqui Dyer, Cabinet Member for Health & Adult Social Care (invited)

Dr Paul Lelliott, Deputy Chief Inspector of Hospitals (lead for mental health), CQC (invited)


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
  • How the right technology can save deteriorating ward patients
  • 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

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

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

Adrian Plunkett, Learning from Excellence (invited)

Patient Safety Collaboratives

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

Jim Blair, Clinical Lead Health Improvement and Quality Learning Disabilities, NHS England (invited)

Dylan Harrison

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

Quality metrics and big data analysis for rapid response and patient safety

  • Understand the latest consensus on RRS from experts and patient representatives
  • How quality metrics guide QI activities and reduce avoidable harm
  • The use of big data analysis and real time dashboards to enhance patient safety

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

12:25 – 13:25

Networking lunch break


How we can really prevent never events

  • Interpret the latest information on never events
  • Explore new approaches to investigating and learning
  • 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

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

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

Professor Anne Marie Rafferty, President, Royal College of Nursing

Angela Reed, Senior Professional Officer, NIPEC

Ensuring safe care for older people living with frailty

  • Understand how to ensure our systems are fit for caring for an ageing population
  • Discuss how community rapid response teams could improve care for frail and elderly people at home
  • How one trust transformed admissions, allowing patients to return home with support

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

Lynn Pantling, District Nurse, Luton (invited)

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

Safe staffing levels and mortality in hospitals

  • Understand the latest research on nurse staffing levels
  • The link between staffing levels and missed vital signs, leading to mortality in hospitals
  • How to develop workforce capacity and family-centred end of life car for acute and critical care

Professor Maureen Coombs, Professor in Clinical Nursing, University of Plymouth

Professor Peter Griffiths, Chair of Health Services Research, University of Southampton (invited)

14:10 – 14:40

Afternoon break in exhibition hall


Human Factors: Quickfire learning

  • Using the Pecha Kucha style of presenting, hear quick fire 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

Creating a safe culture for patients

  • Learn about international safety culture work and how to scale research
  • How to enact evidence-based culture improvement
  • Understand how to create a safe culture for patients

Imperial PSTRC

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

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
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

By continuing to use the site you agree to our cookies policy. Accept