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. The post holder will use data systems to collate information for reports and to identify the need for future investigations. They will manage several investigations simultaneously, creating systems and processes to ensure that data from one incident review does not inappropriately contaminate another. The post holder will be the lead reviewer for all the incident reviews they are working on, organising and coordinating the work of associate investigators and advisory panels.
The post holder will support Chairs (Executive Director and Non-Executive Directors) during the lifetime of a level three adverse inclined review. They will develop expertise in investigation techniques through attendance at national courses, analysing the outcomes of local investigations, considering improvements, and reading specialist articles/reports. The post holder will ensure that deadlines set by commissioning are met, or that requests for extensions are made in a timely manner with sufficient rationale.
They will actively participate in the mortality review process, identifying individual learning points and thematic trends. The post holder will provide advice and support to those affected by serious untoward events and their carers, meeting with managers, practitioners, clinicians, and relatives following serious incidents to consider issues arising, learning resulting, and service responses required.
Responsible for planning the review process within the parameters set by external guidance and the case-specific terms of reference, the post holder will organise and arrange their own work and coordinate the work of others. Based on the findings and recommendations 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 within the directorate and across the Trust. The findings and recommendations will impact audit activity, initiating or amending audit processes.
The post holder will liaise with Directorate and Trust staff to ensure lessons learned from reviews are acted upon and used positively to improve and develop services. They will attend Directorate and Trust Governance meetings and support training and development days/sessions throughout the year. Communication of follow-on actions will be supported after consulting with the line manager, other senior managers, clinicians, and recommendations from groups or committees.
Providing clinical support to identify incidents, 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), the post holder may be called to give evidence to Coroners Courts relating to their investigation findings and to Trust board/Divisional board meetings. They will facilitate Oxford Model Learning Events to share findings of serious untoward incidents with staff.
Effective communication on various levels is essential, developing and maintaining good working relationships with senior managers, practitioners/clinicians in service areas of the Trust subject to review, Safety and Risk Manager, Head of Quality and Compliance, Deputy Director of Nursing and Professions, Heads of Profession, Clinical Directors, and the Executive Team, as well as external agencies (e.g., Safeguarding Boards, other providers).
The post holder will deliver RCA Training to equip staff with the skills and knowledge to undertake investigations into complaints and adverse incidents using Root Cause Analysis techniques. They will ensure information regarding RCA/SIRIS and audit and lessons learned is effectively communicated within the Trust and to external stakeholders, including patients, relatives, and carers, outlining required actions from individual practitioners/clinicians and teams.
The post holder will maintain an RCA caseload and coordinate other external reviews, such as domestic homicide reviews, ensuring Trust representation and completion of casework requirements as necessary. They will undertake the training process related to all deaths occurring in the Trust, implement the mortality policy, and conduct mortality reviews with clinical colleagues as per national guidance.
Additionally, the post holder will undertake Level 2 and 3 Root Cause Analysis reviews and thematic reviews in association with clinical colleagues, provide advice and guidance on reviewing deaths, and identify learning. They will develop mortality reports for various committees in the organisation.
Liaising with families as Duty of Candour lead, the post holder will share information from incident reviews and support them through the coronial process. They will also liaise with staff and families during the root cause analysis process, feedback review reports in a conducive style for learning, and write RCA reports in the agreed Trust style and standard.
Finally, the post holder will participate in Trust validation of root cause analysis reports.
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