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Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020

Brummell, Z; Braun, D; Hussein, Z; Moonesinghe, SR; Vindrola-Padros, C; (2023) 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 , 12 (1) , Article e002093. 10.1136/bmjoq-2022-002093. Green open access

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Abstract

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.

Type: Article
Title: Is anybody 'Learning' from deaths? Sequential content and reflexive thematic analysis of national statutory reporting within the NHS in England 2017-2020
Location: England
Open access status: An open access version is available from UCL Discovery
DOI: 10.1136/bmjoq-2022-002093
Publisher version: http://dx.doi.org/10.1136/bmjoq-2022-002093
Language: English
Additional information: This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Keywords: Health policy, Hospital Mortality, Patient safety, Qualitative research, Quality improvement, Humans, State Medicine, England
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Surgery and Interventional Sci
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Surgery and Interventional Sci > Department of Targeted Intervention
URI: https://discovery.ucl.ac.uk/id/eprint/10165069
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