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Aim: To explore and develop a peer support role for people involved in learning reviews arising from serious incidents. The aim of the role is that service users and their families who have been involved in the serious incident process as a result of either themselves or a family member experiencing a serious incident are trained to provide peer support to service users and their families who are currently experiencing that process.

This project sits within a larger strategic piece of work to embed co-production and a recovery focused model at Lancashire Care with a particular focus on serious incidents

Co-producing quality improvements is a priority for the Trust and is supported through our on going commitment to the co-designing of always events.


Serious incidents investigations within the Trust are led by a central Learning and Investigations Team who draw upon their investigation skills and experiences in facilitating the process in accordance with the Serious Incident Framework (2015: sec 4.2.1) which  outlines the responsibilities of the bodies involved in reviewing incidents to those who are affected by or involved in them. The team work to involve people in the terms of reference for the investigation and in aspects of the report. It is acknowledge that this in the context of being an investigation lead and not as a person or a family who has lived experience of a serious incident and having an understanding of the associated impacts.

The argument for peer support is well documented in areas of managing stress and mental health but less so in for people who use services in this type of process. Peer support may help to address the challenge identified by Wu and Steckelberg (2012) that “it is less well recognised that the investigation itself holds the potential to cause additional harm.” They further quote Scott et al (2009) who describes this as ‘enduring the inquisition’.

The Trust has identified that this is an area where we could explore the role of peer supporters, those with lived experience, to offer those involved ‘outside’ the organisation with  appropriate, timely and person centred support during the learning review and potentially through engaging in co-designed improvements.

This project aims to explore, develop and test a peer support model. It is recognised that this type of role may potentially present challenges to those offering peer support and psychological support will be an essential component of the programme both in terms of training to peer supporters and providing support to the peer supporter.

It is hoped that this approach will improve the quality and learning from serious incidents as families and people who use services are supported and feel more able to engage in the process. This approach aims to provide support to people and their families so they can better anticipate the process and the potential emotional impact of the experience with support from someone who has been through a similarly difficult experience; recognising this is a very difficult time for them, for example they may be grieving the loss of a family member whilst having to go through a formal NHS process.

How will this be measured?

Process: Every person affected by an incident review will be offered a trained peer supporter who works to a role descriptor.

Outcome: People who use services and their families experience will improve; this will be measured in levels of satisfaction and willingness to engage and not feeling supported by the process

Balancing measures: Peer supporters feedback – feeling empowered to support and emotionally coping with being a peer supporter.

Offers to the wider Q Community;

Sharing of the learning from a co-designed approach to providing peer support.

Development of key links with other Trusts testing similar and aligned ideas to ensure sharing of learning.

Financial Support

In order to deliver a sound and tested model we would request that the following funding is considered.


Involvement Payments 10 people for 3 days                                                      £1800

Expenses including refreshments and travel for experts by experience             £1200

Admin support Band 4 0.2 WTE    for 6 months                                                  £3000

Development of support packs for peer supporters                                            £2000

Training development and delivery                                                                      £16000

Project Management Band 7 0.2 WTE for 6 months                                           £5000


Total                                                                                                                     £29000



NHS Serious Incident Framework (2015) Accessed at 11 May 2018

Wu, AW, Steckelberg RC. Medical Error, incident investigations and the second victim: doing better but feeling worse? BMJ Qual Saf 2012

Scott SD, Hirschinger LE, Cox KR,et al. The natural history of recovery for the health care provider ‘second victim’ after adverse patient events. Qual Saf Health Care 2009;18:325–30.

How you can contribute

  • Sharing of experience and models around the use of peer supporters during investigations and reviews.


  1. Thanks for your feedback Simon, I think there is already some great work going on in both areas and locally we are developing those support for staff already. This will build on that and I would hope that we could learn for each approach as I am sure that there is things we can do for both groups to ensure they feel engaged and supported as fully as we can.

  2. I think there's a need for this project - service users and families who have experienced an incident are isolated, far more so than staff, and would appreciate peer support in such a situation.  Several Trusts have carers / service users on the serious incident review teams and similar roles. Have you spoken to them around their learning?

    1. HI Simon - with apologies - I wasn't intending to start competitive isolation!

      There is another proposal (from Nottingham) using TRiM to signpost staff after incidents. Its got a lot of support, which suggests there is a need for that work. Perhaps, as you say, their work could also benefit from having service users and families involved.

      As a family member, not within a Trust, it can feel, rightly or wrongly, like professionals close ranks, and we don't know where to turn to for support after an incident. It's reassuring to see a Trust taking the initiative with this proposal, and recognising that peer support might be the way forward.

    2. Very important work. But I don't think I concur with the "far more so than staff" element of Karen's post. Being caught up in a never event or serious incident review can be profoundly isolating for the clinicians and managers involved.

      It may be a different project, but I would suggest there is real mileage in doing something similar for staff. (With involvement of service users and their families where possible).*


    3. Thanks Karen - I wasn't aware of this. Please do share who they are, it would be great to hear what we can learn from.

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