A narrative account of the key drivers in the development of the Learning from Deaths policy

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

INTRODUCTION

Regulation through statutory reporting is used in healthcare internationally to improve accountability, quality of care and patient safety. Since 2017, within the National Health Service (NHS) in England, NHS Secondary Care Trusts (NSCTs) are legally required to report annually both quantitative and qualitative information related to patient deaths within their care within their publicly available Quality Accounts as part of a countrywide patient safety programme: The Learning from Deaths (LfDs) programme.

METHOD

All LfDs reports published between 2017 (programme inception) and 2020 were reviewed and evaluated through a critical realist lens, quantitatively reported using descriptive statistics and qualitatively using reflexive thematic analysis.

RESULTS

In 2017/2018, 44% of NSCTs reported all six statutory elements of the LfDs reporting regulations, in 2019/2020 35% of NSCTs were reporting this information. A small number of NSCTs did not report any parts of the LfDs regulatory requirements between 2017 and 2020. Multiple qualitative themes arose from this study suggesting problematic engagement with the LfDs programme, erroneous reporting accuracy and errors in written communication.

CONCLUSIONS

The LfDs programme has, to some extent, reduced variation and improved consistency to the way that NSCTs identify, report and investigate deaths. However, 3 years into the LfDs programme, the majority of NSCTs are not reporting as required by law. This makes the validity of National statutory reporting in Quality Accounts within the NHS in England questionable as a regulatory process.

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 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.

Understanding the factors influencing implementation of a new national patient safety policy in England: Lessons from 'learning from deaths'

OBJECTIVE

A new patient safety policy, 'Learning from Deaths' (LfD), was implemented in 2017 in National Health Service (NHS) organisations in England. This study examined how contextual factors influenced the implementation of LfD policy and the ability of the programme to achieve its goals.

METHODS

Semi-structured interviews were undertaken with key policymakers involved in the development of the policy, along with interviews with managers and senior clinicians in five NHS organisations responsible for implementing the policy at the local level. We also undertook non-participant observation of relevant meetings and documentary reviews of key organisation procedures and policies pertaining to LfD.

RESULTS

The study findings suggest several factors that hinder or support patient safety policy implementation at a local level. These include: (a) an organisation's capacity and capability to support data collation, analysis and synthesis, (b) the dissemination of the resulting information, (c) the learning culture and hence perceptions of the purpose of LfD within an organisation, and (d) the extent of engagement in cross-organisational approaches to learning.

CONCLUSIONS

Extra and intra-organisational contextual factors influence all stages of the policy implementation process from preparation and tracking to implementation support and review affecting its chances of success or failure. Successful adoption of a national patient safety policy within health care organisations can be informed by taking into consideration those factors.