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

Mirza Lalani,Helen Hogan

doi:10.1177/13558196211010850

Abstract

ObjectiveIn recent years there has been a proliferation of patient safety policies in the United Kingdom triggered by well publicized failures in health care. The Learning from Deaths (LfD) policy was implemented in response to failures at Southern Health National Health Service (NHS) Foundation Trust. This study aims to develop a narrative to enable the understanding of the key drivers involved in its evolution and implications for future national patient safety policy development.MethodsA qualitative study was undertaken using documentary analysis and semi-structured interviews (n = 12) with policymakers from organizations involved in the design, implementation and assurance of LfD at a system level. Kingdon’s Multiple Streams Approach was used to frame the policymaking process.ResultsThe publication of the Southern Health independent review and subsequent highlighting by the Care Quality Commission of a fragmented approach to learning from deaths across the NHS opened a ‘policy window.’ Under the influence of the families affected by patient safety failures and the then Secretary of State, acting as ‘policy entrepreneurs,’ recently developed methods for mortality review were combined with mechanisms to enhance transparency and governance. This rapidly created a framework designed to ensure NHS organizations identified remedial safety problems and could be accountable for addressing them.ConclusionsThe development of LfD exhibits several common features with other patient safety policies in the NHS. It was triggered by a crisis and the need for a prompt political response and attempts to address a range of concerns related to safety. In common with other safety policies, LfD contains inherent tensions related to its primary purpose, which may hinder its impact. In the absence of formal evaluations of these policies, deeper understanding of the policymaking process offers the possibility of identifying potential barriers to goal achievement.

Highlights

In the United Kingdom (UK), over the last 20 years, there has been a proliferation of patient safety policy initiatives, performance measurement approaches and campaigns emanating from government, regulators and professional bodies
Methodology for reviewing deaths: The policy recommends the adoption of systematic case sampling and review of patient deaths using Structured Judgement Review or other suitable tools.[6]
Using ‘off-the-shelf ‘solutions (NMCRR, Learning Disabilities Mortality Review Programme (LeDeR), Duty of Candour (DoC)) to generate the new policy and accelerate its delivery may have some advantages – rationalizing discrete programmes with which organizations are already familiar under a single umbrella programme while mitigating some of the negative impacts of ‘top-down’ policymaking, increasing legitimacy, feasibility and support.[31]

Summary

Introduction

In the United Kingdom (UK), over the last 20 years, there has been a proliferation of patient safety policy initiatives, performance measurement approaches and campaigns emanating from government, regulators and professional bodies. The history of patient safety in the UK clearly shows that against a backdrop of incremental efforts to improve the surveillance and management of safety across the National Health Service (NHS), it is often the impact of high profile health care scandals and the initiatives in response that lead to changes in policy direction.[1]. The Bristol inquiry into deaths of children with cardiac problems identified a hierarchical culture with limited attempts to learn from failures.[2] The proposed solution was greater transparency across the NHS through the publication of comparable mortality statistics. The Mid Staffordshire inquiry revealed a reluctance from the organization to heed concerns raised by JJoouurrnnaall ooff HHeeaaltlthhSSeerrvviciceessRReeseseaarcrchh&&PoPloicliycy260(04). Families and a lack of transparency when issues arose This led to the Duty of Candour (DoC), a mandatory requirement for NHS staff to be open with families when failings in care arise.[3]

Methods

Results

Discussion

Conclusion