NOA hosts thought provoking webinar focussed on learning from never events and serious incidents


NOA’s latest webinar, Learning From Never Events and Serious Incidents, held on 25 May, brought together experts in orthopaedics, clinical negligence litigation, patient safety, and medical education to discuss an important topic on the health agenda. Never events and serious incidents are a cause for concern and anxiety when reported in an organisation. They require investigation and official reporting to the Care Quality Commission (CQC). The end result should be a process of open multidisciplinary analysis and discussion led by the Clinical Governance team that results in learning for the organisation. This process can be difficult and sensitive when harm is identified, and errors attributed to processes and individual staff. 

The lunchtime session which had over 40 attendees, featured guest speakers including Lecturer in Law, John Tingle, from the University of Birmingham Law School and Mr Perbinder Grewal, a General and Vascular Surgeon, Human Factors & Patient Safety Trainer, and Emotional Intelligence Practitioner who leads on medical education both locally and nationally.


NOA Webinar Lead and Consultant Orthopaedic Surgeon at the Robert Jones and Agnes Hunt Orthopaedic Hospital (RJAH), Cormac Kelly, chaired the session. He kicked off with an overview of the COVID recovery situation nationally with a particular focus on elective waiting lists. He then gave an overview of the topic of focus for the webinar including sharing recent examples of never events and serious incidents locally at his Trust. He concluded his intro with a  live poll asking attendees to respond to the statement ‘I get regular updates of all the Never Events/serious incidents in my organisation’. 61% of attendees said ‘yes’, 22% said ‘no’ and 17% said ‘Don’t know’.

The first guest speaker, Mr Perbinder Grewal then shared a thought-provoking presentation. From decision making and fatigue to interruption, variability, environment and much more – Perbinder took attendees through the many reasons for never events and what filters we can put in place to prevent them from happening in the first place.

Following Perbinder’s presentation, Cormac shared another live poll with attendees which asked them to respond to the statement, ‘My organisation shares the learning from Never Events/Serious incidents’ . 60% said ‘regularly’, 40% said ‘rarely’, 0% said ‘Never’ and 0% said ‘Don’t know’.

The final speaker was Lecturer in Law, John Tingle from the University of Birmingham Law School who shared an overview of the drift towards common never events and covered recent CQC prosecution and NHS patient safety culture.

Following John’s presentation, Cormac shared the final session live poll which asked attendees to respond to the statement ‘I have attended a Human Factors training course’. 39% said ‘never’, 39% said ‘Once in the past five years’ and 22% said “More than once in past five years’

An animated question and answer session and panel discussion followed which sparked hard hitting conversation and debate. The session which was described by one attendee as ‘very good and thought provoking’ can be viewed in full here.

For the latest on NOA events, check out the NOA events pages.