Maria Dineen, MD of Consequence UK
A state registered midwife by profession, Maria Dineen moved into patient safety in 1994, and now has 20 years of experience in the field.

In 1994 she developed one of the first patient-focused adverse incident databases, within the maternity service at the John Radcliffe Hospital, Oxford. She also developed a successful ‘learning from experience model‘ within the service.

Maria worked as an assessor for the Clinical Negligence Scheme for Trust’s 1995 – 1997. This was an illuminating experience, as the concept and application of risk management as it applies to patient safety was very new to England at the time.

Taking her ideas, passion and commitment to patient safety back into mainstream health Maria took a post as the Corporate Clinical Risk and Claims Manager in the then Worcester Royal Infirmary (1997 – 2000). In this role she pursued a culture of openness and honesty with patients, as well as championing the whole-team and across-team reviews. The Trust developed this approach towards patients with plaintiff solicitors in the region over this period and clinicians came to believe that ‘risk management’ as an entity within hospital was worthwhile.

Maria also held a post as a Research Fellow at the Health Services Management Centre Birmingham University (1997 – 2001). Her exposure to the research world and the opportunity to study her main area of interest (adverse incident and claims management) was instrumental to enabling her to try out new ways of approaching adverse events and to develop a structured method for determining a reasonable level of investigation for individual adverse events. This led to her presenting a 5×5 coloured risk tool at the International Quality in healthcare Conference in Dublin in 1998. This tool had been subject to robust testing across the then clinical risk network in the West Midlands.

Maria was Associate Director of Governance at Oxford Mental Health Trust (2000 – 2001).

In 2002 she worked as a Contractor to the Department of Health, collaborating with a Memory Team, and then the National Patient Safety Agency. In this capacity she developed the prototype for investigating and analysing adverse events in healthcare. As a consequence, she was a contributor to the design of the National Patient Safety Agency’s root-cause analysis approach and tool-kit.

In 2002, Maria wrote and published the textbook, ‘Six Steps to RCA’. This is now in its 3rd edition and is in use as the RCA Manual across many authorities within the NHS.

In 2001 Maria formed Consequence UK, which became a limited company in 2003. Its focus at that time was the delivery of effective investigation and root-cause analysis training. Since then Consequence UK has become one of the most prolific providers of effective investigation and root-cause analysis training across the NHS in England and the NHS in Scotland.

In 2004, CUK was engaged as part of a team conducting a public inquiry into a safeguarding adults case, in Birmingham: ‘The Avonside Review’. This heralded a significant development for the company and subsequently it has been invited to tender for and lead independent investigations following serious adverse events.

Maria Dineen also writes for professional journals and she is active on Twitter @maria_dineen and on LinkedIn. Maria is committed to campaigning for the understanding and application of effective investigations practice that can enable practitioners to learn from experiences across healthcare – practising open and honest communications with patients, their families, organisations and teams delivering care.

Maria and CUK are regularly invited to executive-level board meetings to facilitate discussion and provide insight across the strategic health authorities. CUK’s, the team of associates and networked professionals makes the company an authoritative and worthy independent consultancy to consider.

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