Worcestershire Acute Hospitals NHS Trust
Patient Safety Incident and Inquest Manager
Closing date: 15 June 2026
Job Summary
The implementation of the Patient Safety Incident Response Framework (PSIRF) has transformed how the Trust and the NHS responds to patient safety incidents, introducing a more flexible, transparent, and learning–focused approach. Concurrently we have seen increasing involvement and scrutiny with our coronial processes. These changes have created substantial new responsibilities for the Patient Safety Team (PST), including urgent case reviews, family engagement, and coordination with legal and coronial services.
The role presents an opportunity for a highly motivated individual to shape and strengthen these processes and ensure compliance, learning and reputational protection, in particular in relation to the coronial aspect.
Main Duties of the Job
The post supports the Patient Safety Team, the Head of Patient Safety and works with Divisional Governance Teams. It provides leadership, oversight and expert advice to ensure effective reviews of inquests.
Monitor and support processes to ensure timely reports and documents are ready for inquests, with appropriate actions, learning and completion through required governance. Undertake and participate in investigations as needed to review patient safety events and identify learning.
Support learning from a wide range of patient safety information sources (e.g., mortality reviews, incidents, complaints), identifying themes and trends and linking them to current improvement activity and identifying new quality improvement areas.
Establish effective communication, ensuring sensitive, contentious and complex information is handled appropriately when shared with staff, patients, families and colleagues. Liaise with patients, service users, carers and families after a patient safety incident and throughout response processes, supporting active engagement.
Liaise with the legal team on upcoming inquests that may present complications (e.g. neglect verdicts or regulations) for the Trust or staff and escalate issues to the Head of Patient Safety.
Support the Head of Patient Safety to ensure learning from inquests is fed back to the Trust for wider learning and monitor Prevention of Future Deaths regulations issued by the coroner, ensuring the required process is followed.
Inquest Management Activity
Liaise with the legal team about upcoming inquests that could represent complications (neglect verdicts or regulations) for the trust or staff representing the trust and escalate any issues to the Head of Patient Safety. Liaise and coordinate with the legal team to ensure all relevant information has been obtained for upcoming inquests and, if necessary, raise potential delays or concerns to the Head of Patient Safety. Support the Head of Patient Safety with facilitating the learning from inquest and feeding it back to the Trust for wider learning. If required, represent the trust at inquest. Monitor prevention of future deaths regulations issued by the coroner to the trust, supporting the Head of Patient Safety to ensure the process is followed.
Key Duties
* Establish and maintain appropriate and effective lines of communication, ensuring that sensitive, contentious and highly complex information is managed effectively when communicated to staff, patients and their families and colleagues.
* Liaise with patients, service users, carers and families following a patient safety incident and throughout response processes, encouraging and supporting active engagement.
* Liaise with external colleagues and appraise them (as required) of quality assurance in relation to patient safety incidents, reviews and inquests.
* Support the Head of Patient Safety and Complaints and Associate Director of Clinical Governance and Risk to ensure educational programmes reflect the learning acquired from complex investigations (including inquests and claims), influencing the learning and development of all staff.
* Provide line management to existing patient safety team staff as delegated.
* Provide expert advice, guidance and support to all staff on matters related to patient safety incident investigations and responses. Ensure compliance at all times with local and national guidance.
* Support learning from a wide variety of patient safety related information sources (mortality reviews, incidents, complaints, litigation cases), drawing themes and trends, matching this to existing or previous improvement activity.
* Work autonomously as an investigator and in conjunction with subject matter experts and clinical colleagues, escalating any identified risks to the Head of Patient Safety and Complaints.
* Assist with the development, implementation and delivery of the Trust’s Patient Safety Strategy, the Patient Safety Incident Response Framework and Patient Safety Incident Response Plan.
* Base all decision making upon knowledge of applicable codes of practice and quality standards.
* Support the production of comprehensive reports on new, closed, and investigations in progress and thematic trends for review by different audiences as directed, analysing data for trends and learning opportunities on a monthly, quarterly and annual basis.
* Undertake thematic reviews/trend analysis (as required) leading to involvement and implementation of quality improvement projects with clinical teams/services.
* Signpost staff involved in incidents to the appropriate support network internally and externally.
* Support the patient safety and clinical teams and services in the development of SMART action plans to embed and sustain learning into clinical practice, working collaboratively with clinical and operational partners.
* Work with clinicians and managers to identify significant risk (related to PSII) and areas for improvement across clinical and non‑clinical areas.
* Ensure PSIIs are conducted for the sole purpose of learning and identifying improvements which prevent or significantly reduce recurrence.
* Develop close working relations and provide supervision as appropriate to delegated staff including the Patient Safety Administration Assistant.
* Support patient safety campaigns and be part of the leadership team guiding these, especially those related to higher level risks.
* Support the development of key performance indicators with the Head of Patient Safety and Associate Director of Clinical Governance & Safety that demonstrate correlation between incidents, learning and improving the quality of care for patients.
* Support the presentation of reports and key learning points to a wide variety of committees and groups, covering complex information and potential contentious issues, providing a compelling discussion/rationale for change.
* Identify Trust‑wide and divisional trends and themes, producing reports that identify key learning and actions, working with the Patient Safety Learning & Improvement Lead, the corporate and divisional teams on the progression and closure of actions with particular reference to those related to regulations from the coroner.
Person Specification
Qualifications
* Qualification at degree level or equivalent level of knowledge gained through experience.
* Experience in investigation and analysis report writing.
* Experience in inquest processes.
* Healthcare professional qualification or equivalent experience.
* Experience and knowledge in improvement methodology training.
* Degree level education in relevant subject or extensive health service experience in patient safety and risk management.
Skills and Knowledge
* Demonstratable experience of using national reporting and learning systems, Datix systems and other safety related information systems.
* In‑depth knowledge of the Duty of Candour process, confident and able to work directly with families in support of complex investigations.
* Excellent written and verbal communication, able to present complex and contentious information to a wide variety of staff or patient level groups.
* Analytical skills and the ability to draw qualitative and quantitative data from a wide range of sources and draw appropriate conclusions and present in a clear manner.
* IT literate, confident in the use of Word, Excel to undertake analysis of data and production of graphical reports.
* Strong persuasive skills, able to problem solve, find solutions and make recommendations for actions.
* Experience of managing conflicting ideas and actions, finding common solutions and agreeing actions.
* Capable of providing clinical supervision to a network of staff (safety leads).
* Knowledge and understanding of national patient safety policy and strategy.
* Knowledge and understanding of human factors, systems thinking methodology and just culture.
Experience
* Extensive experience working in a patient safety, quality or inquest related role.
* Experience of working closely with clinicians and managers of varying seniority, on key projects or improvement activities.
* Experience of developing and delivering improvement plans that focus on improved safety and quality for patients and staff, making adjustments and changes to ensure success.
* Experience of writing and presenting reports and verbal updates to Trust Board and associated sub‑committees.
* Able to develop new policy, guidelines or operating procedures in line with improvement activity.
* Ability to lead Trust‑wide safety improvement projects, working with a range of clinicians and patient groups in developing and implementing key actions.
* Ability to analyze complex information (including patient safety incident data, administrative data, mortality data), drawing themes, conclusions and actions.
* Evidence of staff management and leadership skills.
* Experience of writing and presenting reports and verbal updates to Trust Board and associated sub‑committees.
* Experience of developing and delivering educational and training programmes.
* Experience of direct line management of staff, setting annual objectives, undertaking appraisals and providing ongoing support.
* Experience of auditing and surveying own work and that of the wider team, to determine the effectiveness and impact of approaches and work streams.
* Evidence of successfully managing change at divisional level.
* Evidence of working with patient groups as part of improvement activity.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.
Employer name
Worcestershire Acute Hospitals NHS Trust
DBS Checks and Costs
Any applicants who are offered posts requiring a DBS check as part of their employment check will have the cost of this check (at the current rate) deducted from their salary. Please see link in SupportingInformation section for more details on DBS checks and costs.
#J-18808-Ljbffr