NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme

Abstract

ObjectivesTo review how National Health Service (NHS) Secondary Care Trusts (NSCTs) are using the Learning from Deaths (LfDs) programme to learn from and prevent, potentially preventable deaths.IntroductionPotentially preventable deaths occur worldwide within healthcare organisations. In England, inconsistencies in how NSCTs reviewed, investigated and shared LfDs, resulted in the introduction of national guidance on ‘LfDs’ in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and LfDs’. Amendments to NHS Quality Account regulations, legally require NSCTs in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended NSCTs would share this learning and take measurable action to prevent future deaths.MethodWe undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222).ResultsAll statutory elements of LfDs reporting were reported by 98 out of 222 (44%) NSCTs. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of NSCTs (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 NSCTs (48%) have shared or plan to share the learning within their own organisation. The majority of NSCTs (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 NSCTs (17%) mentioned involvement of bereaved families.ConclusionsThe wide variation in reporting demonstrates that some NSCTs have engaged fully with LfDs, while other NSCTs appear to have disengaged with the programme. This may reveal a disparity in organisational learning and patient safety culture which could result in inequity for bereaved families. Many themes identified from the LfDs reports have previously been identified by national and international reports and inquiries.

National statutory reporting: not even ticking the boxes? The quality of ‘Learning from Deaths’ reporting in quality accounts within the NHS in England 2017–2020

“…When we previously reported on the quality of 2017/2018 LfDs reporting, we noted that reporting variation may be due to differences in interpretation of the guidance and statutory requirements; however, 3 years should be sufficient time to get to grips with reporting requirements. 683 The incentive to report appears clear: to demonstrate quality of care and safety for patients; however, the penalty for not reporting is less clear, there is no direct financial penalty for an NSCT not reporting LfDs. The only sanction facing NSCTs is that they may be notified to take action following CQC inspections.…”

“…Quantitative analysis was undertaken and reported using descriptive statistics. The qualitative methodology used was a process of data familiarisation (reading each report twice on separate occasions), systematic data coding, generating initial domains deductively, 683 then developing multidimensional themes inductively through active engagement and immersion in the data, looking both at what was present and what was absent. Finally, these themes were refined by sense checking with the original reports and discussion with the other authors.…”

National statutory reporting: not even ticking the boxes? The quality of ‘Learning from Deaths’ reporting in Quality Accounts within the NHS in England 2017-2020

“…When we previously reported on the quality of 2017/18 LfDs reporting, we noted that reporting variation may be due to differences in interpretation of the guidance and statutory requirements; however three years should be sufficient time to get to grips with reporting requirements. [23] The incentive to report appears clear: to demonstrate quality of care and safety for patients; however, the penalty for not reporting is less clear, there is no direct financial penalty for an NSCT not reporting LfDs. The only sanction facing NSCTs is that they may be notified to take action following CQC inspections.…”

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

“…A deductive approach to content analysis was undertaken, informed by Brummell et al (2020) paper and previous research and enquiries analysing deaths due to problems in care as described in the introduction. [1] Content analysis, then reflexive TA, were sequentially used to analyse: learning, actions taken as a result of learning, an assessment of impact of these actions, how bereaved families had been involved in any learning and if/how learning had been shared. With reflexive TA a deductive then subsequent inductive approach was used to assess NSCT engagement with the LfDs programme.…”