Training Case Studies - Silver Human Factors Training

Human Factors Training (silver) – Noel Devine, Lead Serious Incident Investigator


“The Silver Human Factors Training allowed me to reflect on how I worked in using the Yorkshire Contributory Factors Framework in my investigations.”

Noel Devine is a Lead Serious Incident Investigator for South West Yorkshire Partnership NHS Foundation Trust within the Patient Safety Support team. Noel is a retired Detective Inspector from the West Yorkshire Police and has been in his current post for over 6 years.

Working with a team of three full-time investigators Noel’s role is to investigate serious untoward incidents together with a Consultant Psychiatrist, and to run training courses in relation to root cause and systems analysis. As part of the investigation the team meets with families before and after the investigation.

Prior to attending the Silver Human Factors Training course, Noel had attended a contributory factors training organised by the Trust. Noel and his team have been using the Yorkshire Contributory Factors Framework as part of their investigation process for several years as they had recognised the important part it played. Attending the Silver Human Factors Training allowed Noel to reflect on how he and his team worked in using the framework in investigations and provided an update to current practices.

Noel’s key learning point from the session was the importance of looking outwards during an investigation when looking for the causes of something that has been identified, rather than working on a blame culture. This is an important learning point for Noel’s organisation currently due to the potential impacts of changes to services in response to the financial constraints; particularly if those changes may have potential impacts on the quality and safety of care provided.

Noel hopes to continue to use the Yorkshire Contributory Factors Framework in his investigations and, through providing advice and training to others, to ensure that they also realise the importance of it.

Noel attended the Improvement Academy Silver Human Factors training day, funded through the Yorkshire and Humber AHSN on 13th November 2018.