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SAFER CARE SYLLABUS > UNDERSTAND & LEARN

Building Competency in Significant Event Reviews

 Build confidence and practical capability in Level 1 Significant Event Audits. This one-day programme gives health and social care professionals a structured approach to gathering and analysing information, engaging patients and staff, identifying learning and contributing to meaningful recommendations and action plans

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Duration

1 day

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Delivery

1 day interactive workshop.

Online or Face to Face

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Level

Intermediate

Some experience helpful

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CPD

External accredition

8 CPD points

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Why this course?

Significant Event Audits provide a structured way to understand what happened, identify learning and support safer care.

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This programme develops the practical skills needed to participate effectively in a Level 1 review — from establishing the facts and engaging those involved through to analysis, recommendations and report development.

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What will you learn

Develop the knowledge, skills and confidence to:

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Apply a structured Systems Analysis approach to a Level 1 Significant Event Audit, moving beyond individual actions to understand how wider system factors shaped the event.

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Reconstruct what happened with rigour, using chronology development, fact-finding and multiple sources of evidence to build a reliable picture of the event..

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Engage patients, service users, families and staff meaningfully, ensuring their perspectives inform the review while supporting a fair and Just Culture approach.

Analyse why the event happened using Systems Analysis methodology, identifying and articulating causal and contributory factors and examining how those factors interacted within the wider system.

Translate analysis into meaningful learning, developing recommendations that address the factors identified through the review rather than relying on superficial or generic actions.

Produce a clear, credible SEA report and action plan, with findings and recommendations that are evidence-based, proportionate and capable of supporting improvement.

Who should attend?

Health and social care professionals and managers who are leading or participating in Level 1 Significant Event Audits and want to build their incident-review knowledge and practical skills.

Course Content

The programme follows a structured review journey, guiding participants from understanding the event through to analysis, learning and action.

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INTRODUCTION – Understanding the review context: Current approaches to incident review, the purpose of Level 1 Significant Event Audit and the guidance underpinning a proportionate, systems-based review.

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DISCOVER – Establishing what happened: Chronology development, structured fact-finding and gathering information from relevant sources.

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ENGAGE – Involving the people affected:

Practical approaches to engaging patients, service users, families, carers and staff, including Just Culture principles

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ANALYSE – Understanding why it happened: Applying Systems Analysis methodology to identify causal and contributory factors and understand how they interact within the wider system.

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ACT – Turning learning into improvement:

Developing meaningful recommendations and action plans that address the factors identified through the review.

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REPORT – Bringing it together:

Producing a clear, credible SEA report that links the evidence, analysis, findings and recommendations.

Practical learning, built around a real review

The programme is highly practical and applied, using multiple health and social care case studies that reflect the working environments and services represented by participants.

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Working in groups, participants apply the methodology throughout the programme — developing chronologies, gathering and testing information, considering the perspectives of those involved, analysing causal and contributory factors, and developing recommendations.

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Using a range of realistic scenarios helps participants understand how the same structured review approach can be applied across different care settings and builds confidence in using the methodology in their own organisation.

A practical toolkit for the workplace

The programme is supported by a practical suite of tools and resources designed to help participants apply the methodology confidently after the workshop.

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Participants receive access to the CLS Build App, providing a digital space to revisit key learning and access supporting materials when they need them in practice.

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They also leave with:

  • ready-to-use SEA tools and editable templates to support each stage of the review;

  • multiple case studies and worked examples that reflect a range of health and social care settings;

  • reference materials and practical guidance to reinforce the Systems Analysis approach;

  • resources to support analysis, recommendation development and report writing; and

  • ongoing access to programme materials, allowing participants to revisit the learning as they apply it in their own workplace.

Designed around your organisation

The programme is designed to be relevant to the organisation and the people taking part. Before delivery, we work with you to understand your local procedures, review arrangements and the services represented by participants, so the learning reflects the context in which they actually work.

 

For organisations, this means:

 

  • Training aligned to local procedures — programme content can reflect your organisation’s review processes, terminology and governance arrangements.

  • Case studies that feel relevant — scenarios are selected to reflect the clinical, social care and service environments represented by participants.

  • Practical application to real roles — participants work with examples and exercises that mirror the types of reviews they are likely to undertake.

  • A more consistent organisational approach — teams build a shared understanding of Systems Analysis methodology and the expectations for Level 1 Significant Event Audits.

  • Evidence of learning impact — pre- and post-programme evaluation measures changes in participants’ knowledge, confidence and learning.

Ready to build this capability

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