Course Description

This one-day virtual course is designed to familiarise delegates with the purpose of a Coroner’s Inquest and civil litigation and explain how patient safety investigation reports/other learning responses might be used by the Courts.

The course is interactive and includes role-play and case studies. We can work with clients to develop bespoke case studies.

Delegates will learn:

• The purpose of a Coroner’s Inquest
• The relationship between a safety action plan and Prevention of Future Death Reports (Regulation 28)
• The rules of disclosure and how investigation outputs and their supporting documents may be used at court
• How action plans or outcomes from an investigation could form part of wider improvements across an organisation or care system
• How to produce evidentially sound investigation reports:
  • The skills to scope an incident and gather evidence; what sort of evidence is required
  • How to deal with conflicting evidence
  • How to organise evidence
  • Critical analytical skills
• Evidential standards at Coroner’s Court and Civil Court
• Statement writing
• The processes and environments connected with litigation and/or Inquests
• How to prepare for court
• Courtroom skills

Timings

09.00am to 09.15am  Logon, housekeeping, overview and introductions

09.15am to 09.30am  The purpose of a Coroner’s Inquest, possible conclusions and reports to prevent future deaths

09.30am to 09.40am  How Coroners use investigation reports and how they approach the evidence base

09.40am to 10.00am  How to write a learning response report that will stand up to scrutiny

10.00am to 10.30am Producing evidentially sound investigation/learning response reports

10.30am to 10.45am  Coffee Break

10.45am to 11.45am  Recap. Organising evidence.

11.45am to 12.30pm   Dealing with conflicting evidence

12.30pm to 1.30pm   Lunch

1.30pm to 1.45pm      Understanding and being able to use critical analytical skills

1.45pm to 2.15pm      How to support staff to write statements that will withstand robust questioning

2.15pm to 2.30pm      The rules of disclosure at Coroner’s Court and in litigation proceedings, including what supporting documents may be used

2.30pm to 2.45pm      Tea Break

2.45pm to 2.55pm      The processes and environments connected with litigation and/or Coronial proceedings

2.55pm to 3.45pm       Preparing staff for giving evidence during coroner’s court and what to expect if you are a witness

3.45pm to 3.50pm      The relationship between an action plan and Prevention of Future Death Reports (Regulation 28)

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

Organisations are now transitioning over to the Patient Safety Incident Response Framework (PSIRF).  All patient safety incidents will have to be undertaken by investigators who have been on a two-day course. This training meets the PSIRF requirements.

This two-day course is delivered virtually via MS Teams or Zoom. It can be delivered face-to-face on request.

The training is practical and case study led, with day one being a non-clinical case study and day two a clinical case study designed to fit the needs of an organisation.

We use breakout rooms for most of the exercises to create a protected learning environment.

Delegates will learn:

• The purpose and overriding principles of the Patient Safety Incident Response Framework (PSIRF)
• The different types of learning response prescribed by PSIRF
• How to undertake a Patient Safety Incident Investigation (PSII)
• About complex systems, systems thinking and human factors
• How just culture fits into the patient safety arena
• The application of the duty of candour
• How to support and engage with staff, patients, families and carers throughout a learning response
• How to conduct interviews
• How to conduct observations in order to understand work as done
• The additional evidence required
• Methods of analysis; how to use the SEIPS model and the Yorkshire Contributory Factors Framework
• The SEIPS work system template
• How to map and organise evidence
• How to produce meaningful and actionable safety actions and safety recommendations
• How to create effective measurement plans
• Robust and accessible report writing techniques
• The importance of monitoring the effectiveness of safety actions and recommendations

Timings

Day One

09.00am to 09.30am  Logon, technical knowhow and introductions

09.30am to 10.00am   Overview of PSIRF. Different types of learning response. What is a PSII?

10.00am to 10.30am  A practical introduction to complex systems, systems thinking and human factors

10.30am to 10.45am  Coffee Break

10.45am to 11.15am  A practical introduction to complex systems, systems thinking and human factors continued

11.15am to 11.30am  How a just culture works in practice

11.30am to 11.45am Applying the duty of candour

11.45am to 12.15pm  How to support and compassionately engage with staff, patients, families and carers through an incident response

12.15pm to 1.15pm   Lunch

1.15pm to 2.15pm      How to conduct interviews under PSIRF

2.15pm to 2.30pm      Tea Break

2.30pm to 3.30pm      How to conduct observations, understanding work as done

3.30pm to 3.45pm       Collecting other types of evidence

3.45pm to 4.00pm      Recap and questions

Day Two  

09.00am to 09.15am  Recap, housekeeping, timings and overview of the day.

09.15am to 10.30am   Analysing the evidence using the SEIPS 2.0 model and the Yorkshire Contributory Factors Framework

10.30am to 10.45am  Coffee Break

10.45am to 11.15am  Mapping the evidence

11.15am to 11.30am  Additional analysis techniques

11.30am to 12.30pm How to produce meaningful and actionable safety actions and safety recommendations

12.30pm to 1.30pm   Lunch

1.30pm to 1.45pm      Report production.

1.45pm to 2.15pm       Monitoring learning reviews

2.15pm to 2.30pm      Tea Break

2.30pm to 3.45pm      Extended case study testing each step of a PSII investigation with discussion sessions built in

3.45pm to 4.00pm      Recap, questions, summary and feedback

Basic Description of Course

The Mental Capacity Act (MCA) is a vital piece of healthcare legislation, governing decision-making on behalf of adults who may not be able to make decisions for themselves. Everyone working with or caring for adults who may lack capacity to make decisions must comply with the MCA and its Code of Practice. However, all too often, health and social care staff are unsure of how the Act works in practice – they lack the confidence to carry out mental capacity assessments and are unfamiliar with how to make best interests decisions.

This course will give a complete overview and explanation of key parts of the MCA. It will cover the key principles of the MCA, explain in practical terms how to conduct a capacity assessment and describe how best interests decisions should be made. It will also cover the Deprivation of Liberty Safeguards, and touch upon what changes are likely to be brought about when the Liberty Protection Safeguards (LPS) are introduced.

This is an essential course for all health and social care staff working with adults who may lack the capacity to make decisions for themselves, and will also help prepare them for when the LPS comes into force.

Course Objectives

• Understand the key principles of the MCA
• How to undertake capacity assessments and the test for “lack of capacity”
• How to implement best interests decision making
• Record keeping
• Advance care planning and advance decisions
• Restraint under the MCA, and the limits to this
• When does restraint turn into a deprivation of liberty?
• How are deprivations of liberty authorised?
• An overview of the LPS – key provisions and changes that will be introduced

Course Timetable

Basic Description of Course
This interactive and practical course will provide a structured approach to complaints handling through the use of systems analysis. The day will also cover letter writing, communicating with patients/service users/carers and families and conducting interviews. All techniques will be tested through role-play.

Course Content

• Overview of a systems-based approach as it relates to complaints handling
• Scoping the complaint; clarifying and breaking down the issues
• Information collection
• Interface with the Duty of Candour and complaints procedure
• Meeting with patients and families
• Letter writing; ensuring that all issues are covered
• Interview techniques
• Time management
• Dealing with serial complainers

Course Timetable
9.30am to 10.00am             Coffee and Registration
10.00am to 10.30am           Delegate’s experience of handling complaints and undertaking investigations is established

10.30am to 11.15am             An overview of a systems-based approach
11.15am to 11.30am              Coffee Break
11.30pm to 12.00pm            Scoping case study; ensuring clarification of the issues
12.00pm to 12.30pm           Meeting with family members, carers and patients
12.30pm to 12.45pm            Role play
12.45pm to 1.15pm               Lunch
1.15pm to 1.45pm                 Interviews
1.45pm to 2.00pm               Exercise
2.00pm to 2.30pm              Using timelines to structure analysis
2.45pm to 3.00pm              Tea Break
3.00pm to 3.30pm              Drafting response letters including dealing with serial complainers
3.30pm to 4.00pm              Summary
4.00pm                                  Conclusion

Basic Description of Course

The Liberty Protection Safeguards (LPS) are still in the process of being implemented. They will in due course replace the Deprivation of Liberty Safeguards (DOLS).

The course will give practical guidance on what you and your staff can be doing to prepare for the implementation of the LPS in order to make the transition as smooth as possible. 

It is essential that all front-line staff be up to date and familiar with how to undertake capacity assessments and best interest assessments.  They will need to have an in-depth understanding of what constitutes a deprivation of liberty and what steps to take now and under the new legal framework. 

Delegates will have the opportunity to raise issues and concerns specific to their own practice. 

This session will enhance a practitioner’s understanding of the principles and how to apply them in practice.

Course Objectives

• A practical overview of the Mental Capacity Act 2005
• How to undertake capacity assessments 
• How to undertake best interests assessments 
• Advance care planning and advance decisions
• The interface between the Mental Health Act and the Mental Capacity Act
• Record keeping
• An overview of the LPS – key provisions and changes that will be introduced
• Understand the LPS timeline – key milestones and activities taking place ahead of implementation

Course Timetable 

9.30am to 10.00am        Coffee and Registration

10.00am to 10.30am            Overview of the Mental Capacity Act 2005

10.30am to 11.15am              Interface between the Mental Capacity Act and Mental Health Act. Recent case law discussion. 

11.15am to 11.30am         Coffee Break

11.30am to 12.45pm             Capacity Assessments and record keeping

12.45pm to 1.30pm         Lunch

1.30pm to 2.45pm                Best Interests Assessments, Advance Decisions and record keeping 

2.45pm to 3.00pm          Tea Break

3.00pm to 3.15pm                What constitutes a Deprivation of Liberty

3.15pm to 3.45pm                 An overview of the LPS – key provisions and changes that will be introduced

3.45pm to 4.00pm          Finish

Course Overview

Healthcare professionals are frequently asked to write witness statements for a Coroner or called to attend an Inquest hearing to give evidence. This often provokes worry or anxiety, and witnesses can feel intimidated by the Inquest process.

This practical course is designed to help overcome those fears. Starting with statement writing, it explains why a witness statement is required, what it should cover and how it should be structured. The course then moves on to a clear and full explanation of the Inquest process from start to finish. All practical aspects are covered, including who will be in attendance at Court, what to wear, what to call the Coroner and how best to answer questions. It also covers some more of the more difficult issues, such as what to do if lawyers are present, how to deal with their techniques, juries and expert witnesses.

The course will focus on Inquests with a mental health element to them, and is aimed primarily at mental health professionals, but it is open to all.

Course Objectives

• Learn how to write a clear and complete witness statement, and why this is so important.
• Learn what an Inquest is and why it is required. In particular, understand what role the Coroner plays and what he/she can and can’t do.
• Learn when a jury will be called, and what this means in practical terms.
• Be given practical tips on what to wear, what to expect on the day and what support you will have.
• Learn how to be a good witness and how to give clear and honest evidence.
• Gain an understanding of what makes a “bad” witness, and how to avoid this.
• Be given tips on how to deal with lawyers’ techniques when questioning witnesses.
• Learn when an expert witness is required, what their role is and how this might affect you.
• Understand how a Serious Untoward Investigation will be used by the Coroner.
• Understand the possible conclusions a Coroner (or jury) can return, and whether there will be any further ramifications.
• Gain an understanding of what a Prevention of Future Deaths report is.

Course Timetable

This virtual one-day training session will provide delegates with the expertise in involving patients, families, carers and staff in patient safety incident investigations.

The emphasis will be on practicality; the day is case study led.  Delegates will be guided through communicating openly and honestly with patients and families, having difficult conversations, gathering evidence (conducting interviews) and complying with the Duty of Candour.

There will be a structured approach to assisting staff to write excellent witness statements as well as conducting formal interviews in a ‘just culture’.

Signposting patients, families, staff and carers to appropriate support will also be covered.

The session will also cover how to effectively involve patients, families, carers and staff when working remotely.

All techniques will be tested through role-play.

Delegates will learn:

• How to communicate openly and honestly
• How to issue an apology and say sorry
• How to conduct meetings with patients and families
• Managing expectations
• Recognition of patients, families and carers that may need additional support through the investigation process and how to access that support
• How to work with the duty of candour, information sharing and confidentiality
• Involving advocates and points of contact
• Multi-agency working and dealing with parallel investigations
• How to help staff produce excellent witness statements
• How to conduct interviews with staff in a blame free/fair blame culture
• How to signpost patients, families, carers and staff to support
• Feeding back to patients, families, carers and staff

Timings

09.00am to 09.15am  Logon, technical knowhow and introductions

09.15am to 09.45am  Principles of being open

09.45am to 10.15am  Duty of Candour

10.15am to 10.45am  Apologies; verbal and written

10.45am to 11.00am  Coffee Break

11.00am to 11.45am  Arranging meetings with family members, carers and patients, including arranging additional support

11.45am to 12.00pm  Managing expectations

12.00am to 12.30pm Gathering evidence and difficult conversations

12.30pm to 1.00pm   Lunch

1.00pm to 1.15pm      A Just Culture; fair evaluation of the actions of staff

1.15pm to 1.20pm      Addressing accountability in the context of ‘no blame’ investigations

1.20pm to 1.45pm      Supporting staff

1.45pm to 2.30pm      Interviewing staff; planning and conducting

2.30pm to 2.45pm      Tea Break

2.45pm to 3.15pm      Feeding back to staff and patients, families and carers

3.15pm to 3.45pm      Multi-agency working and dealing with parallel investigations

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

This virtual training session will focus on the first crucial steps of any incident investigation.  The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day, as well as one that can be conducted remotely. Mirroring the new Patient Safety Strategy, good practice and factors requiring change will be identified, along with their contributory factors.  All recommendations, reports and action plans will focus on systemic changes, multi-disciplinary working and implementing practical changes.  All learning points are reinforced with real life examples.  Delegates will be provided with a suite of templates to use during an investigation as part of our commitment to an holistic approach to patient safety.

This course can also be run over 2 half-days.

Delegates will learn:

• How much information to gather and how to gather it

• The role of human factors and ergonomics in patient safety incidents

• How to involve patients, families and carers

• How to organise evidence using Timelines

• How to critically analyse evidence

• How to conduct interviews with staff members and families

• Identification of factors requiring change

• Including good practice in reports

• Identification of contributory factors

• Identification of broken and missing systems

• Making proportionate and effective recommendations

• Pulling a report together

Timings

09.00am to 09.15am  Logon, timings and housekeeping

09.15am to 10.00am  Introductions and an overview of the investigation methodology.

10.00am to 10.15am  Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach, the importance of objectivity and tips for achieving neutrality.

10.15am to 10.45am  Gathering information; a report is only as good as the information it is based on.  Investigators must beyond simply gathering evidence to find out ‘what’ happened – they must find and ‘why’ it happened and remember to gather human factors and ergonomic evidence. This will ensure that Investigators possess enough evidence to make SMART recommendations.

10.45am to 11.00am  Coffee Break

11.00am to 11.45am  Mapping the information using simple and tabular timelines.

11.45am to 12.15am  Critical Analytical Skills – How to identify missing or incomplete evidence

12.15am to 12.30pm Summary

12.30pm to 1.00pm   Lunch

1.00pm to 1.15pm      Recap on Module 1

1.15pm to 1.45pm      Critical Analytical skills – how to prepare for interviews. How to conduct interviews with staff members and families

1.45pm to 2.30pm      Identification of good practice and factors requiring change.  The importance of standards and precision writing.

2.30pm to 2.45pm      Tea Break

2.45pm to 3.15pm      Identifying contributory factors, including human factors, broken and missing systems.

3.15pm to 3.45pm      Focus on writing excellent recommendations, benchmarking, reasonable/measurable action plans and producing standardised reports.  Example report format provided.

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

This virtual 2-day training session will focus on the first crucial steps of any incident investigation.  The emphasis will be on practicality and a process that can be incorporated into the health professional’s working day, as well as one that can be conducted remotely. In line with the new Patient Safety Strategy delegates will be taught how to identify both good practice and care delivery problems will along with their contributory factors.  The session includes modules on Information Collection and Organisation, Human Factors, Precision Writing and the production of SMART recommendations. 

Delegates will be provided with a suite of templates to use during an investigation as part of our commitment to an holistic approach to patient safety.

Delegates will learn:

• How much information to gather and how to gather it
• The role of human factors and ergonomics in patient safety incidents
• How to involve patients, families and carers
• How to organise evidence using Timelines
• How to critically analyse evidence
• How to conduct interviews with staff members and families
• A guide to precision writing
• Identification of good practice
• Identification of care delivery problems
• Identification of contributory factors
• Identification of broken and missing systems
• The key elements of SMART recommendations
• How to pull the final report together

Course Timetable – Day 1

9.00am to 09.15am    Logon, technical knowhow and introductions

09.15am to 09.30am  Overview of the investigation methodology.

09.30am to 9.45am    Human factors and ergonomics; this session will explore how human factors can influence an investigator’s approach, the importance of objectivity and tips for achieving neutrality.

9.45am to 10.15am    Gathering information; a report is only as good as the information it is based on.  Investigators must beyond simply gathering evidence to find out ‘what’ happened – they must find and ‘why’ it happened and remember to gather human factors and ergonomic evidence. This will ensure that Investigators possess enough evidence to make SMART recommendations.

10.15am to 10.30am  Coffee Break

10.30am to 11.15am  Mapping the information using simple and tabular timelines.

11.15am to 11.45am  Critical Analytical Skills – How to identify missing or incomplete evidence

 11.45am to 12.00pm Conclusion, Questions and Set up for Module 2

12.00pm to 1.00pm   Lunch

1.00pm to 1.15pm      Recap on Module 1

1.15pm to 1.45pm      Critical Analytical skills – how to prepare for interviews. How to conduct interviews with staff members and families

1.45pm to 2.30pm      Identification of good practice and care delivery problems.  The importance of standards and precision writing.

2.30pm to 2.45pm      Tea Break

2.45pm to 3.15pm      Identifying contributory factors, including human factors and broken and missing systems using wagon wheel and barrier analysis.

3.15pm to 3.45pm      Focus on writing excellent recommendations, benchmarking, reasonable/measurable action plans and producing standardised reports.  Example report format provided.

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

Course Timetable – Day 2

9.00am to 09.15am    Logon, technical knowhow and introductions

09.15am to 10.15am  Witness statement case study

10.15am to 10.30am  Coffee Break

10.30am to 12.00pm  Planning for interview.  Question drafting case study

12.00pm to 1.00pm   Lunch

1.00pm to 2.30pm      Incident Investigation case study from start to finish.  Reports will be submitted to and marked by the trainers.

2.30pm to 2.45pm      Tea Break

2.45pm to 3.15pm      Case study continued.

3.15pm to 3.45pm      Delegates receive feedback on their incident investigation reports.

3.45pm to 4.00pm      Summary, questions, conclusion and feedback

This interactive virtual workshop (for a maximum of 18 delegates) looks, in detail, at the common mistakes investigators make.

Delegates will work on a real incident report and will use lessons learnt during the one-day Incident Investigation training to constructively critique it. 

Issues that will be explored include quality of information collection, misuse (or non-use) of tabular timelines, un-structured critical analysis, the use of vague language, failure to take into account human factors and ineffective recommendations.

The workshop will also explore how to provide encouraging and effective feedback to investigators.

Delegates will learn:

• How to identify inadequate information collection
• How to spot when an investigator has not used the correct investigation tools, including Tabular Timelines
• How to identify deficient critical analysis
• How to ameliorate vague language
• The key components of a well-drafted recommendations
• How to provide constructive feedback to investigator

Course Timetable

10.00am to 10.15am  Registration and Introductions

10.15am to 10.30am  Overview/recap of RCA

10.30am to 10.45am  Case Study – delegates review report and provide initial feedback

10.45am to 11.15am  Information gathering.  Group work.  Delegates review report in light of discussion.

11.15am to 11.30am  Coffee Break

11.30am to 11.45am  Simple timelines.  Group work.  Delegates review report in light of discussion.

11.45am to 12.00pm  The use of tabular timelines.

12.00am to 12.30pm  Additional information required.  Group work.

12.30pm to 1.00pm    Critical analysis: factors requiring change and good practice.  Precision writing.  Group work.

1.00pm to 1.30pm      Lunch

1.30pm to 2.45pm      Critical analysis: contributory factors (including Human Factors) and barrier analysis.  Group work.

2.45pm to 3.00pm      Coffee Break

3.00pm to 3.30pm      Recommendations and Action Plans.  Group work.

3.30pm to 3.45pm      Providing constructive feedback.

3.45pm to 4.00pm      Conclusion