Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020
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 requir...
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| Format: | Article |
| Language: | English |
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BMJ Publishing Group
2023-03-01
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| Series: | BMJ Open Quality |
| Online Access: | https://bmjopenquality.bmj.com/content/12/1/e002093.full |
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| author | Cecilia Vindrola-Padros S Ramani Moonesinghe Zoe Brummell Dorit Braun Zainab Hussein |
| author_facet | Cecilia Vindrola-Padros S Ramani Moonesinghe Zoe Brummell Dorit Braun Zainab Hussein |
| author_sort | Cecilia Vindrola-Padros |
| collection | DOAJ |
| description | 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. |
| format | Article |
| id | doaj-art-fa970145395641ceb467d18cc1158cf6 |
| institution | DOAJ |
| issn | 2399-6641 |
| language | English |
| publishDate | 2023-03-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
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| spelling | doaj-art-fa970145395641ceb467d18cc1158cf62025-08-20T02:52:49ZengBMJ Publishing GroupBMJ Open Quality2399-66412023-03-0112110.1136/bmjoq-2022-002093Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020Cecilia Vindrola-Padros0S Ramani Moonesinghe1Zoe Brummell2Dorit Braun3Zainab Hussein4Department of Applied Health Research, University College London, London, UKDepartment of Targeted Intervention, University College London, London, UKDepartment of Targeted Intervention, University College London, London, UKAdvisor/Lived experience, London, UK1University Hospitals Coventry and Warwickshire, Clifford Bridge Road, Coventry, WMD CV2 2DX, UKIntroduction 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.https://bmjopenquality.bmj.com/content/12/1/e002093.full |
| spellingShingle | Cecilia Vindrola-Padros S Ramani Moonesinghe Zoe Brummell Dorit Braun Zainab Hussein Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 BMJ Open Quality |
| title | Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 |
| title_full | Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 |
| title_fullStr | Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 |
| title_full_unstemmed | Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 |
| title_short | Is anybody ‘Learning’ from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017–2020 |
| title_sort | is anybody learning from deaths sequential content and reflexive thematic analysis of national statutory reporting within the nhs in england 2017 2020 |
| url | https://bmjopenquality.bmj.com/content/12/1/e002093.full |
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