© Victoria Morgan 2016

Serious incident thematic reviews

Tackle the common underlying causes of serious incidents


Multidisciplinary teams will identify and plan improvements to address the causes of serious incidents in their organisation’s maternity units.  This facilitated, half-day, interactive workshop is held on your premises and is suitable for a group of 5–20 delegates.  Delegates receive pre-workshop packs containing an analysis of their maternity units’ serious incidents (using anonymised data supplied by their organisation); at the workshop delegates will receive a handout of the slides (with references for further reading) and a template to record their PDSA cycle.

The process is designed to uncover systems and human factors that require addressing; not manage the performance of individual members of staff.


  • Identify common themes in a series of serious incidents.
  • Agree the core content for maternity serious incident reports to ensure a common understanding of current risks by teams.
  • Identify key questions to be answered in investigations.
  • Identify any gaps in investigations that have been conducted and take steps to resolve those gaps.
  • Identify themes or root causes that might require further investigation.
  • Design, implement and review interventions to prevent further serious incidents and/or reduce the impact of future incidents using the Model for Improvement and plan-do-study-act (PDSA) cycle methodology. 

What will delegates achieve?

  • Work as a multidisciplinary team to improve clinical quality in maternity services.
  • Set and monitor standards for serious incident reporting.
  • Describe the common underlying factors for different categories of maternity serious incidents.
  • Agree priorities for action.
  • Design interventions to improve the quality of maternity services informed by the Model for Improvement and PDSA cycle.

Who should attend?

Multidisciplinary teams from each maternity unit - midwives, obstetricians, support staff (including those overseeing serious incident reporting) and parents. 

You might also like to consider inviting commissioners, GPs, neonatologists, obstetric anaesthetists, paediatricians and public health representatives, for example.

What happens before the workshop?

Every Birth a Safe Birth will work with your serious incident co-ordinator to prepare the information and agenda for the delegate packs using our methodology to visualise safety trends.

What happens after the workshop?

Delegates will receive support to follow through their action plans, celebrate success and develop their ideas through a closed, online discussion forum.

A record of actions agreed will be provided to those who attended the workshop, linked to the relevant serious incident(s).

Electronic certificates of attendance will be available to all delegates, who can claim up to 3 CPD credits for full attendance at the workshop.

All delegates will be asked to complete an evaluation questionnaire.  A report summarising the findings will be sent to the person booking the workshop.


Victoria Morgan


£1,080 per workshop plus reasonable travel and subsistence expenses.

Annual support package:  10% discount when booking four or more workshops in any 12 month period.


Other services you may be interested in

Maternity clinical networks

Quality improvement workshops