Display options
Cite
Brummell Z, Vindrola-Padros C, Braun D, et al. NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. BMJ Open. 2021;11(7):e046619doi: 10.1136/bmjopen-2020-046619.
Brummell, Z., Vindrola-Padros, C., Braun, D., Moonesinghe, S. R., Quiñones, S., & Kiyama, J. M. (2021). NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. BMJ open, 11(7), e046619. https://doi.org/10.1136/bmjopen-2020-046619
Brummell, Zoe, et al. "NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme." BMJ open vol. 11,7 (2021): e046619. doi: https://doi.org/10.1136/bmjopen-2020-046619
Brummell Z, Vindrola-Padros C, Braun D, Moonesinghe SR, Quiñones S, Kiyama JM. NHS 'Learning from Deaths' reports: a qualitative and quantitative document analysis of the first year of a countrywide patient safety programme. BMJ Open. 2021 Jul 07;11(7):e046619. doi: 10.1136/bmjopen-2020-046619. PMID: 34233980; PMCID: PMC8264864.
Copy Download .nbib Format: NLM
Share it on

BMJ Open. 2021 Jul 07;11(7):e046619. doi: 10.1136/bmjopen-2020-046619.

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

BMJ open

Zoe Brummell, Cecilia Vindrola-Padros, Dorit Braun, S Ramani Moonesinghe, Quiñones, Kiyama

Affiliations

  1. Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK [email protected].
  2. Department of Anaesthesia and Intensive Care Medicine, University College London Hospitals NHS Foundation Trust, London, UK.
  3. Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK.
  4. Advisor/Lived experience, London, UK.
  5. National Institute for Academic Anaesthesia, Royal College of Anaesthetists, Health Services Research Centre, London, UK.

PMID: 34233980 PMCID: PMC8264864 DOI: 10.1136/bmjopen-2020-046619

Abstract

OBJECTIVES: To 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.

INTRODUCTION: Potentially 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.

METHOD: We undertook qualitative and quantitative secondary data, document analysis of all NSCTs LfDs reports within their 2017/2018 Quality Accounts (n=222).

RESULTS: All 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.

CONCLUSIONS: The 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.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.

Keywords: health & safety; health policy; organisational development; qualitative research; quality in health care

Conflict of interest statement

Competing interests: ZB worked at NHS Improvement in the medical directorate from August 2017 to August 2018, during which time she undertook some work on the LfDs programme. SRM is the National Clini

References

  1. Qual Saf Health Care. 2009 Apr;18(2):153-6 - PubMed
  2. BMJ. 2002 Oct 19;325(7369):895-900 - PubMed
  3. Qual Saf Health Care. 2002 Mar;11(1):51-6 - PubMed
  4. BMJ Qual Saf. 2019 Jan;28(1):49-55 - PubMed
  5. Medicine (Baltimore). 2017 Feb;96(8):e6162 - PubMed
  6. Int J Health Policy Manag. 2018 Nov 21;8(2):136-137 - PubMed
  7. BMJ Qual Saf. 2017 Jun;26(6):484-494 - PubMed
  8. BMJ Qual Saf. 2012 Sep;21(9):737-45 - PubMed
  9. BMJ Open Qual. 2017 Sep 24;6(2):e000123 - PubMed
  10. BMJ. 2019 Jun 20;365:l2239 - PubMed
  11. Acad Med. 2014 Sep;89(9):1245-51 - PubMed
  12. Implement Sci. 2006 Oct 30;1:27 - PubMed
  13. BMJ Qual Saf. 2021 Mar;30(3):177-179 - PubMed
  14. Int J Health Policy Manag. 2018 Feb 18;7(7):662-666 - PubMed
  15. BMJ. 2017 Aug 2;358:j3453 - PubMed

MeSH terms

Publication Types