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A practice-based approach that facilitates reflection and learning

“This is a highly valuable course that has informed me in great depth on how to achieve improved investigation outcomes that keep away from ‘blame’ ‘fear’ etc & applies the principles of justice. It has set my mind onto much greater critical thought processes.”

All areas of the United Kingdom have been reviewing how public sector and private organisations respond to unexpected incidents of harm. In England the Patient Safety Incident Response Framework (PSIRF) develops key messages espoused in the Serious Incident Framework for England (2015). In Scotland, Wales and Northern Ireland review and refinement of their respective national approaches is also occurring. All strive to achieve the following characteristics. An inclusive, systematic, compassionate, and proficient response to patient safety incidents. All promote the principles of openness, fair accountability, learning, and continuous improvement.


Consequence UK’s principal Maria Dineen has always been a strong advocate of this approach and has been embracing it in her own investigations since as early as 1998. This passionate commitment to openness, honesty, and transparency is in clear evidence in our training programmes.


Our programmes champion the value of working effectively with patients, families, and staff through the review and investigation process. We consider what it means to investigate and the importance of taking time to reflect. In this way, our programmes empower individuals and enable a cultural shift that sees incident responses as a valuable way to improve future patient safety both with frontline teams but also the wider organisation.

A blended learning approach

Our training programmes take place over a period of weeks or months. They use a blended learning approach consisting of video-based podcasts, face-to-face discussion and reflection with skilled facilitators, and self-directed practical experimentation with tools and ideas. The approach offers practical benefits because participants can fit the programme into busy schedules more easily. There is also less impact on service delivery and staffing levels. Most importantly, it gives participants time to reflect on their learning, try new practices, and consider new ways of working all within a safe and supportive learning structure.


“If the trust offers more/different leadership training provided by the same instructors, I will definitely be on the list in the future.”


    Investigating Well I:

    In depth Patient Safety Incident Investigations (PSII) and Proactive Safety Investigation

    Audience: Individuals who will become the core cohort of patient safety investigators for their employing organisation undertaking systemic reviews of the most difficult, challenging and complex cases.

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    Investigating Well II:

    Culture, Approach, and Oversight

    Audience: Individuals with a patient safety leadership role at executive, director, and service management levels. Also those instructing, quality assuring, and signing off patient safety improvement projects, and patient safety and other adverse incident investigation reports.

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    Case Assessment:

    How to Conduct a Defendable Rapid Review of Care and Support a Proportionate Approach to Learning from Harm

    Audience: Frontline team leaders, their deputies, matrons, lead clinicians and service managers.

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    Hearts and Minds:

    Learning, Candour, and Accountability

    Audience: Individuals in any role that would gain from reflecting on their understanding of what it means to learn effectively from harming events, and what it means to engaging well with patients and families after harm.

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    Patient Safety Reviews (PSRs):

    Achieving proportionate well-informed and credible reviews of low – moderate harm, and near miss Incidents. Also complaints, and professional performance issues

    Audience: PSR facilitators, and Team leaders and their deputies. In clinical services, the lead consultant or lead health professional for the patient and his/her deputy/senior training grade staff.

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