2019 Programme

2019 Programme

Patient Safety Congress 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 – 09:55

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

Ray James, National Learning Disability Director, NHS England and Improvement

Sue Jones, Patient Representative

09:55 – 10:50

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, NHS England and NHS Improvement
Panel discussion

Professor the Lord Darzi of Denham, Director of the Institute of Global Health Innovation, Imperial College London

Dr Aidan Fowler, National Director of Patient Safety, NHS England and NHS Improvement

Professor Alison Leary, Chair of Healthcare & Workforce Modelling, London South Bank University and University of South Eastern Norway

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, Senior Advisor, Institute of Global Health Innovation, 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 Safety Advocate


The deteriorating patient in a non-acute setting

  • The national perspective on the deteriorating patient
  • The latest achievements by the national Patient Safety Collaborative programme on deteriorating patients in community and non-acute settings
  • Hear about the latest tools to help in non-acute settings

Dr Matt Inada Kim, National Clinical Lead Deterioration, NHS England and NHS Improvement

Dr Hein Le Roux, GP, West of England AHSN​

Matthew Richardson, Deputy Director of Quality and Nursing, NHS West Hampshire Clinical Commissioning Group

Geraldine Rodgers, Associate Director of Nursing, Clinical Effectiveness & Fellow for Older People, North East London FT

Sarah Tilford, Improvement Manager – Patient Safety Programmes, NHS England and NHS Improvement

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, Founder, Novellus Solutions Limited

Spreading best practice governance across independent hospitals

  • Explore the most pressing safety issues for private providers
  • Understand emerging policy on private hospital governance
  • Make improvements in your own work based on best practice

Dr Howard Freeman, Medical Director, Independent Healthcare Providers Network

Mary Greaves Ed.D,​ Patient Representative

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 value of patient safety in the digital age: A data-driven approach

  • Hear the outcome of a research paper commissioned by RLDatix, focusing on how many errors that cause harm to patients can be prevented using data collection and simple operational changes to patient flow
  • Understand how savings from patient safety can be projected by estimating the frequency of the medical error, the cost per error and the efficacy of error reduction interventions
  • Find out how making full use of data can help impact the financial implications of patient safety (potentially £3.8 million per 100,00 admissions)

Sachin Agrawal, President Strategy, Marketing & Data, Datix

Adam E. Block, Assistant Professor of Public Health, New York Medical College

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, Campaigner for better End of Life discussions

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

Joanne Hughes, Patient Representative​

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,​ Associate Director, The South West AHSN

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

Dr Suzette Woodward, Senior Advisor, Department of Health and Social Care

13:05 - 14:05

Networking lunch break


Innovations in wound care

  • Learn about the work of the National Wound Care Strategy Programme
  • Consider the issues around patient experience, safety and NHS costs
  • Understand the emerging recommendations for clinical practice and implications for service delivery

Dr Una Adderley, Director, National Wound Care Strategy Programme, Yorkshire and Humber AHSN

Tracy Goodwin, Patient Representative

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

Dr Yogini Jani, Consultant Pharmacist & EHRS Patient Safety Lead, University College London Hospitals FT​

Paul Lee, Medical Devices Training Manager, Swansea Bay University Health Board, Morriston Hospital

Catherine Maddock, Pain Nurse Lead, Hampshire Hospitals FT

How other countries work to reduce harm

  • Learn about patient safety reporting and proactive measures 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

Dr Jan Maarten van den Berg, Coordinating Inspector, Healthcare Inspection, Netherlands
Dr John Wakefield, Deputy Director-General Clinical Excellence Queensland, Department of Health Queensland

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, Nurse Consultant for critical care and critical care outreach, University College London Hospitals FT

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, NHS Improvement

Kevin Lewis, Head of Registration & Coronial Services, Leicester City Council

Dr Jason Shannon, National Clinical Lead for Mortality Review and Senior Responsible Officer for Medical Examiner Implementation in Wales


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

Lorraine McMullen, Regional Director Health in Justice, Care UK

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

Ian McNeill, Head of the Regional Liaison Service, General Medical Council

Louise Robinson, Principal Liaison Adviser - Midlands and East, General Medical Council

Dr Chris Turner, Consultant in Emergency Medicine, Civility Saves Lives

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 fallacies of work-as-imagined

  • Reflect on the varieties and archetypes of human work
  • Consider some of the fallacies of work-as-imagined
  • Hear examples from a range of healthcare contexts
  • Understand a process for designing human work

Dr Steven Shorrock, Chartered psychologist, chartered ergonomist and human factors specialist

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: Dr Steven Shorrock, Chartered psychologist, chartered ergonomist and human factors specialist

Enabling a learning culture

Chairs: Mike Durkin, Senior Advisor, Institute of Global Health Innovation, Imperial College London and

Susanna Stanford, Patient Safety Advocate

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

First, fast, effective response to 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 to prevent errors with innovative solutions
  • How you can implement practical changes

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

Richard Simcock,​ Human Factors Specialist/Director, Ergonomic Systems Limited


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, Senior Advisor, Institute of Global Health Innovation, Imperial College London

Kelsey Flott, PSTRC Centre Manager, Imperial College London

Erik Mayer, NIHR PSTRC Theme Lead and Transformation CCIO, Imperial College London

Training to achieve a safe maternity service

  • An overview of the national agenda for safety in maternity services
  • 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, Associate Medical Director and Consultant Obstetrician, North West Anglia FT

James Titcombe, Patient Safety Consultant, Baby Lifeline

Sascha Wells-Munro, 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, Director, National Collaborating Centre for Mental Health (NCCMH)

Melanie Leahy, Patient Representative

Dave Riley, Quality Improvement Partner, Mersey Care FT



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
Alison Phillips, Patient Representative

John Welch, Nurse Consultant for critical care and critical care outreach, University College London Hospitals FT

Chairs: Tracey Moore and Liz Staveacre, NOrF Board

NOrF Annual Conference


11:35 – 11:40

Time to move between sessions


Optimising patient safety through behavioural modification – improving the human factors driving best practice and outcome

  • How behavioural changes are vital to reducing common adverse health events and improving patient safety
  • Explore the critical role of industry in delivering behavioural and cultural changes, from automated processes to training and cross sector partnerships
  • Discover the key insights from the ABHI Patient Safety Group on alleviating adverse health incidents
  • Apply the science of behaviour to establish and sustain change which will improve patient experiences, treatment compliance and cost optimisation

Ian Duncalf, Vice Chair, ABHI Patient Safety Working Group

Mike Fairbourn, Chair, ABHI Patient Safety Working Group

Rachel Power, Chief Executive, The Patients Association

Professor Jane Reid, Regional Lead (South of England), Sign up to Safety and Clinical Lead, Wessex Patient Safety Collaborative, Wessex AHSN


Can we really learn anything useful about patient safety from aviation?
  • Discover how safety investigation approaches taken in other industries can be adapted for healthcare
  • Understand the challenges of adapting practices from other industries to healthcare
  • Draw out the key learning points from aviation that you can back to your own organisation
Dr Kevin Stewart, Executive Medical Director and Deputy Chief Investigator, HSIB

Closing the loop: The Cappuccini test - Embedding learning using a patient narrative

  • Hear how the case of Frances Cappuccini has inspired change
  • Learn about the new Cappuccini test
  • Discuss how to adopt the test and key learning for your organisation

Dr David Bogod, Consultant Anaesthetist, Nottingham University Hospitals Trust

Kate Rohde, Partner, Kingsley Napley LLP

Improving community care for patients with learning disabilities and autism

  • 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, Independent Consultant Nurse Learning Disabilities and Associate Professor, Kingston and St. George’s Universities​, Clinical Advisor Learning Disabilities at the Queens Nursing Institute​

Dylan Harrison, Patient Representative

Rob Webster, Chief Executive, South West Yorkshire Partnership FT

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 in Anaesthesia and Intensive Care Medicine, University College London Hospitals FT

Chris Hancock, Acute Deterioration Programme Manager 1000 Lives Improvement, Public Health Wales

Dr Chris Subbe, Consultant Physician, Improvement Science Fellow NHS Wales, Bangor University and The Health Foundation


Chairs: Sarah Quinton and John Welch, 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
Nigel Acheson, Deputy Chief Inspector - 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 important role of patients in Learning from Excellence
  • How finding the best in people is key to spread and adoption
  • How the national patient safety improvement programme (NPSIP) is scaling up excellence: the adoption and spread of the COPD discharge care bundle

Jono Broad, Associate Director, The South West AHSN

Dr Jo Congleton, Respiratory Clinical Lead, Kent Surrey Sussex AHSN & Consultant in Integrated Respiratory Care, Brighton & Sussex University Hospitals FT/Sussex Community NHS FT

Dr Adrian Plunkett, Consultant Paediatric Intensivist, Birmingham Children’s Hospital

Sarah Papworth-Heidel, Improvement Manager – National Patient Safety Improvement Programme, NHS England and Improvement

Ellie Wells, Programme Manager, Kent Surrey Sussex AHSN

Delivering system level learning in maternity

  • Hear examples from the National Maternity and Neonatal Safety Improvement Programme
  • Get an indication of key areas of early learning from HSIB’s maternity safety investigations
  • Learn how to adopt these approaches in your organisation

Phil Duncan, Head of Patient Safety Programmes (Improvement), NHS England and Improvement

Dr Maria Karam, Consultant Neonatologist, Luton and Dunstable University Hospital FT​

Sandy Lewis, Maternity Programme Director, HSIB

Professor James Walker, Clinical Director Maternity Investigations Programme, HSIB

Ensuring safe care for older people living with frailty

  • 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 Hull transform ed admission s, allowing patients to return home with support

Petrina Kaye, Rapid Response Team Lead, Cambridgeshire Community Services Trust

Michelle Pilkington, Community Matron – Specialist in Dementia Care, Cambridgeshire Community Services Trust

Dr Kirsten Richards, Consultant Physician and Clinical Director in Elderly Care, Hull University Teaching Hospitals Trust

Critical Care Outreach: the latest evidence for Rapid Response and their role at the End of Life
  • 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
  • Rapid Response, a Cochrane Review update: Discuss the findings and the included studies
Professor Maureen Coombs, Professor in Clinical Nursing, University of Plymouth

Dr Jennifer McGaughey, Senior Lecturer, Queen’s University Belfast

Chairs: Emma Lynch and Natalie Pattison, NOrF Board


NOrF Annual Conference


14:10 – 14:40

Afternoon break in exhibition hall


Using NEWS across the pathway

  • How to collaborate to implement & measure NEWS in all care settings across a whole region and why this is so important
  • Understand the data from using NEWS in Out of Hours Primary Care
  • Obtain the emerging evidence on using NEWS at referral points

Dr John Caldwell, Medical Lead, Integrated Urgent Care, Research and Quality Improvement, PrimaryCare:24

Dr Matt Inada Kim, National Clinical Lead Deterioration, NHS England and NHS Improvement

Thomas Knight, Clinical Research Fellow, University of Birmingham


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 and scapegoating
  • Hear from Susanna on how she worked with individuals and a specialism to move forward and ensure learning from her experience
  • How to progress towards a more constructive way of giving feedback and moving forward

Dr David Bogod, Consultant Anaesthetist, Nottingham University Hospitals Trust

Professor Iain Moppett, Professor of Anaesthesia & Perioperative Medicine, The University of Nottingham

Susanna Stanford, Patient Safety Advocate


Being fair guidance and charter: supporting a just and learning culture for staff and patients following incidents in the NHS

  • Understand the current issues in relation to fairness, and equity for all involved
  • Share examples of good practice and invite further contributions
  • Promotion of ‘Being fair’ charter for all healthcare related organisations

Dr Denise Chaffer, Director of Safety and Learning, NHS Resolution

Jo Davidson, Associate Director of Workforce - Organisational Effectiveness and Learning, Mersey Care FT

Roger Kline, Research Fellow, Middlesex University Business School

Care of vulnerable people: Quickfire learning

  • Take advantage of short presentations to hear quick fire examples of best practice
  • Learn about how these projects have addressed challenges around safe care for vulnerable patients
  • Make use of Q&A time to ask more specific questions and learn how to address your own challenges

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 and Carmel Gordon-Dack, 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
  • 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, Hon Consultant Surgeon, St Mark’s Hospital, London
Panel discussion

David Sellu, Hon Consultant Surgeon, St Mark’s Hospital, London

Andrea Sutcliffe, Chief Executive and Registrar, Nursing and Midwifery Council

James Titcombe, Patient Safety Consultant, Baby Lifeline

Dr Jenny Vaughan, Law and Policy Lead, The Doctors’ Association UK

Professor Sir Norman Williams, Chairman, National Clinical Improvement Programme


Chair’s closing remarks

Shaun Lintern, Patient Safety Congress Chair




Close of conference

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