Patient Safety ReviewerinWinwickinWinwickPUBLISHED WED 13 NOV 2024

The post holder will be participating in the delivery of learning and change following serious incidents and deaths of service users under the care of the Trust. The post holder will lead investigations, using nationally accepted methodologies in conjunction with clinical divisions, enabling them to identify changes that need to be made to enhance safety and quality.

Shortlisting planned for: 26 November 2024

Interviews planned for: 12 December 2024

1. To evaluate the care, treatment and support in place when serious incidents have occurredin order to inform improvement in the safety and quality of services provided by the Trust.2. To facilitate timely and inclusive case specific reviews; to establish the facts, identify possiblecontributory or causal factors, highlight resultant learning, consider improvements requiredand recommendations from the reports of reviews undertaken.3. To lead comprehensive reviews (Level 2 as set out in the National Patient Safety Agencyguidance relating to Root Cause Analysis (RCA)) into circumstances and / or LeDeR (NationalLearning Disability Review Programme) reviews into the deaths of service users with alearning disability which can be highly complex, sensitive contentious and which requireclinical interpretation.4. Provide advice and support to those affected by serious untoward events and their carers(meeting with managers/practitioners/clinicians/relatives following serious incidents toconsider issues arising, learning resulting and service responses required).

About us

1. The post holder will analyse the outcomes of a series of incidents, identifying similar issues, making recommendations for future learning to the Chief Operating Officers concerned.
2. The post holder will use data systems to collate information for the use in reports and to identify the need for future investigations.
3. The Post holder will manage several investigations at one time, creating systems and processes to ensure that data from one Incident review does not inappropriately contaminate another.
4. The post holder will be the lead reviewer for all the incident reviews that they are working on, organising and coordinating the work of associate investigators and advisory panels.
5. The post holder will support Chairs (Executive Director and Non-Executive Directors) during the lifetime of a level three adverse inclined review.
6. The post holder will develop an expertise in investigation techniques through attendance at national courses, through analysing the outcomes of local investigations and considerationhow improvements could be undertaken and by the reading of specialist articles /reports.
7. The post holder will ensure that deadlines set by commissioning are met or those requestsfor extensions are requested in a timely manner and with sufficient rationale to be accepted.
8. To undertake and actively participate in the mortality review process, identifying individual learning points and thematic trends.
9. Provide advice and support to those affected by serious untoward events and their carers (meeting with managers/practitioners/clinicians/relatives following serious incidents to consider issues arising, learning resulting and service responses required).
10. Responsible for planning the process of reviews, within the parameters set by external guidance and the case specific terms of reference, organising and arranging own work andcoordinating the work of others.
11. Based upon the findings and recommendations arising from the review of serious incidents the post-holder will inform changes to practice and policy of the service area subject to review and other service areas, both within the directorate and across the Trust. Thefindings and recommendations will impact upon audit activity; initiating or amending audit processes.
12. Liaise with Directorate and Trust staff to ensure lessons learnt from reviews are acted upon and used positively to improve and develop services.
13. Attend Directorate and Trust Governance meetings, and support training and development days/ sessions throughout the year.
14. Support the communication of follow on actions, after consulting with i.e. the line manager, other senior managers/clinicians, and recommendations from groups or committees.
15. Provide clinical support to the identification of incidence, themes, trends, recurrence and lessons learned from analysis of RCA, clinical audit and effectiveness data (e.g. regular reports to Safety and Risk and Quality and Safety Committees).
16. The post holder may be called to give evidence to Coroners Courts relating to their investigation findings and to Trust board/ Divisional board meetings.
17. Facilitate Oxford Model Learning Events with the aim of sharing the findings of serious untoward incidents with staff.
18. Communicate effectively on a range of levels, developing and maintaining good working relationships with: -a. Senior managers, practitioners/clinicians in service areas of the Trust subject to review.b. Safety and Risk Manager, Head of Quality and Compliance, Deputy Director of Nursing and Professions.c. Heads of Profession, Clinical Directors and the Executive Team.d. External agencies (e.g. Safeguarding Boards, other providers).
19. Deliver RCA Training with the aim of providing staff with the skills and knowledge to undertake investigations into Complaints and Adverse Incidents using Root Cause Analysis techniques.
20. Ensure information in relation to RCA/SIRIS and audit and lessons learnt are effectively communicated within the Trust and to external stakeholders, including patients, relatives and carers as appropriate and what actions are required of individual practitioners/clinicians and teams).
21. The post holder will maintain a RCA case load; and co-ordinate other external reviews such as domestic homicide reviews ensuring Trust representation and completion of casework requirements as necessary.
22. Undertake the training process in relation to all deaths that occur in the Trust.
23. Implement the mortality policy.
24. Undertake, in association with clinical colleagues, mortality reviews as per national guidance.
25. Undertake, in association with clinical colleagues, Level 2 and 3 Root Cause Analysis reviews.
26. Undertake, in association with clinical colleagues, thematic reviews.
27. Provide advice and guidance on how to review deaths and identify learning.
28. Develop mortality reports for various committees in the organisation.
29. Liaise with families as Duty of Candour lead, sharing information from incident reviews with them and supporting them through the coronial process.
30. Liaising with staff and families as part of the root cause analysis process.
31. Feedback review reports in a style that is conducive to learning.
32. Writing root cause analysis reports in the agreed Trust style and to the agreed standard.
33. Participate in Trust validation of root cause analysis reports.