Improving NHS trusts' learning from patient deaths

When we look at government and health regulatory publications over the last 20 years or so, a stark picture begins to emerge. The publications all seem to speak in similar tones about the same patient safety, health quality problems and challenges. Common solutions are regularly advanced but the same problems stubbornly remain.

In 2000 the seminal document on patient safety and health quality, An Organisation With a Memory, was published (Department of Health, 2000). This publication laid the foundations for patient safety policy development in the NHS and identified several key problems that are still with us today:

‘We believe that, if the NHS is successfully to modernise its approach to learning from failure, there are four key areas that must be addressed. In summary, the NHS needs to develop:

This report also discussed the need for a more open NHS culture when errors are reported. Publications in 2019 are repeating the same messages and calls. The Care Quality Commission (CQC) has recently published a report on progress made by NHS trusts in the first year of implementing national guidance on learning from deaths (CQC, 2019). This shows marked variation in how trusts are implementing the new guidance, with some clearly finding it difficult.