RT Journal Article
SR Electronic
T1 Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020
JF BMJ Open Quality
JO BMJ Open Qual
FD British Medical Journal Publishing Group
SP e002093
DO 10.1136/bmjoq-2022-002093
VO 12
IS 1
A1 Zoe Brummell
A1 Dorit Braun
A1 Zainab Hussein
A1 S Ramani Moonesinghe
A1 Cecilia Vindrola-Padros
YR 2023
UL http://bmjopenquality.bmj.com/content/12/1/e002093.abstract
AB Introduction The imperative to learn when a patient dies due to problems in care is absolute. In 2017, the Learning from Deaths (LfDs) framework, a countrywide patient safety programme, was launched in the National Health Service (NHS) in England. NHS Secondary Care Trusts (NSCTs) are legally required to publish quantitative and qualitative information relating to deaths due to problems in care within their organisation, including any learning derived from these deaths.Method All LfDs report from 2017 to 2020 were reviewed and evaluated, quantitatively and qualitatively using sequential content and reflexive thematic analysis, through a critical realist lens to understand what we can learn from LfDs reporting and the mechanisms enabling or preventing engagement with the LfDs programme.Results The majority of NSCTs have identified learning, actions and, to a lesser degree, assessed the impact of these actions. The most frequent learning relates to missed/delayed/uncoordinated care and communication/cultural issues. System issues and lack of resources feature infrequently. There is significant variation among NSCTs as to what ‘learning’ in this context actually means and a lack of oversight combining patient safety initiatives.Discussion Engagement of NSCTs with the LfDs programme varies significantly. Learning as a result of the LfDs programme is occurring. The ability, significance or value of this learning in preventing future patient deaths remains unclear. Consensus about what constitutes effective learning with regard to patient safety needs to be defined and agreed on.Data are available in a public, open access repository. All data used in this study are publicly available from NHS Secondary Care Trusts Quality Accounts.