About this event

  • Date and time Thu 11 Apr 2019 from 9:00am to 4:30pm
  • Location Royal Society of Medicine
  • Organised by Patient Safety

This event will examine how medical professionals can learn from the devastating outcome of a paediatric death and improve overall patient safety by undertaking best interests decision-making in paediatrics. 

You will hear different perspectives from a Chief Coroner’s view on the role of Coroners and Inquests in learning from deaths, a small project being co-ordinated by NHS Resolution Safety and Learning that is seeking to change the perception of Coroner’s Preventing Future Deaths Reports, to the National Director for Patient Safety will provide an overview of the national learning from deaths framework.

A final session on legal framework will consolidate your learning by underpinning best interests decision-making in paediatrics, the role of CAFCASS on behalf of the patient, and the perspective of clinicians who are involved in these types of decision making processes. 

Topics include: 

  • The role of Coroners (and Inquests) in learning from deaths, including particularly key themes arising out of Coroners’ Preventing Future Deaths Reports nationally 
  • NHS Resolution’s projects that are supporting learning from deaths, including their report on learning from suicide-related claims and a project aimed at changing perceptions regarding Coroners’ Preventing Future Deaths Reports
  • The national learning from deaths framework, including any themes that are emerging nationally, any output from the framework and how it might interact with the planned roll-out of Medical Examiners 
  • The legal background and framework underpinning best interest decision-making in paediatrics 
  • The perspective of the child patient at the heart of these decision-making processes and the role of CAFCASS
  • The experience of clinicians involved in these types of decision-making processes, including reflections and any learning


Key speakers

His Honour Judge Mark Lucraft QC

The Chief Coroner of England and Wales

Dr Aidan Fowler

National Director of Patient Safety, NHS Improvement


View the programme

Registration, tea and coffee
Welcome and introduction

Mr Brady Pohle, Immediate Past President, Patient Safety Section, Royal Society of Medicine

Session one: Improving patient safety by learning from deaths         

Learning from death – the coroner’s perspective

His Honour Judge Mark Lucraft QC, Chief Coroner of England and Wales, Royal Courts of Justice

Changing perceptions – preventing future deaths reports

Justine Sharpe, Safety & Learning Lead London, NHS Resolution

Learning from deaths

Dr Aidan Fowler, National Director of Patient Safety, NHS Improvement

Panel discussion and questions
Lunch and networking

Session two: Best interests in paediatrics

Dr Libby Haxby, President, Patient Safety Section, Royal Society of Medicine 

Chair’s opening remarks
Best interests decision-making – the legal framework and background

Ms Susanna Rickard, Barrister, Serjeants’ Inn Chambers

Difficult decision making – the perspective from the children’s guardian

Teresa Julian, Family Court Advisor and Ms Mihaela C Ionescu, Practice Supervisor, Children and Family Court Advisory and Support Service

Tea and coffee break
Difficult decision-making: Clinicians’ perspective

Dr Duncan Macrae, Consultant, Paediatric Intensive Care, Royal Brompton and Harefield NHS Foundation Trust

Panel discussion and questions
Closing remarks


Royal Society of Medicine, 1 Wimpole St, Marylebone, London, W1G 0AE, United Kingdom