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

Introduction: Potentially preventable deaths occur worldwide within healthcare organisations. Organisational learning from incidents is essential to improve quality of care. In England, inconsistencies in how NHS secondary care trusts reviewed, investigated and shared learning from deaths, resulted in the introduction of national guidance on ‘Learning from Deaths’ (LfDs) in 2017. This guidance provides a ‘framework for identifying, reporting, investigating and learning from deaths’. Amendments to NHS Quality Account regulations, legally require NHS trusts in England to report quantitative and qualitative information relating to patient deaths annually. The programme intended trusts would share this learning and take measurable action to prevent future deaths. / Method: We undertook qualitative and quantitative secondary data analysis of all NHS secondary care trust LfDs reports within their 2017/18 Quality Accounts, to review how organisations are using the LfDs programme to learn from and prevent, potentially preventable deaths. / Results: All statutory elements of LfDs reporting were reported by 98 out of 222 (44%) trusts. The percentage of deaths judged more likely than not due to problems in healthcare was between 0% and 13%. The majority of trusts (89%) reported lessons learnt; the most common learning theme was poor communication. 106 out of 222 trusts (48%) have shared or plan to share the learning within their own organisation. The majority of trusts (86%) reported actions taken and 47% discussed or had a plan for assessment of impact. 37 out of 222 trusts (17%) mentioned involvement of bereaved families. / Conclusions: The wide variation in reporting demonstrates that some trusts have engaged fully with LfDs, while other trusts 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 LfD reports have previously been identified in national and international reports and inquiries. Further work is needed to strengthen the LfDs programme

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

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

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

Downward pumping of magnetic flux as the cause of filamentary structures in sunspot penumbrae

The structure of a sunspot is determined by the local interaction between magnetic fields and convection near the Sun's surface. The dark central umbra is surrounded by a filamentary penumbra, whose complicated fine structure has only recently been revealed by high-resolution observations. The penumbral magnetic field has an intricate and unexpected interlocking-comb structure and some field lines, with associated outflows of gas, dive back down below the solar surface at the outer edge of the spot. These field lines might be expected to float quickly back to the surface because of magnetic buoyancy, but they remain submerged. Here we show that the field lines are kept submerged outside the spot by turbulent, compressible convection, which is dominated by strong, coherent, descending plumes. Moreover, this downward pumping of magnetic flux explains the origin of the interlocking-comb structure of the penumbral magnetic field, and the behaviour of other magnetic features near the sunspot

Modification of cell wall properties in lettuce improves shelf life

It is proposed that post-harvest longevity and appearance of salad crops is closely linked to pre-harvest leaf morphology (cell and leaf size) and biophysical structure (leaf strength). Transgenic lettuce plants (Lactuca sativa cv. Valeria) were produced in which the production of the cell wall-modifying enzyme xyloglucan endotransglucosylase/hydrolase (XTH) was down-regulated by antisense inhibition. Independently transformed lines were shown to have multiple members of the LsXTH gene family down-regulated in mature leaves of 6-week-old plants and during the course of shelf life. Consequently, xyloglucan endotransglucosylase (XET) enzyme activity and action were down-regulated in the cell walls of these leaves and it was established that leaf area and fresh weight were decreased while leaf strength was increased in the transgenic lines. Membrane permeability was reduced towards the end of shelf life in the transgenic lines relative to the controls and bacteria were evident inside the leaves of control plants only. Most importantly, an extended shelf-life of transgenic lines was observed relative to the non-transgenic control plants. These data illustrate the potential for engineering cell wall traits for improving quality and longevity of salad crops using either genetic modification directly, or by using markers associated with XTH genes to inform a commercial breeding programme

The Evershed Effect with SOT/Hinode

The Solar Optical Telescope onboard Hinode revealed the fine-scale structure of the Evershed flow and its relation to the filamentary structures of the sunspot penumbra. The Evershed flow is confined in narrow channels with nearly horizontal magnetic fields, embedded in a deep layer of the penumbral atmosphere. It is a dynamic phenomenon with flow velocity close to the photospheric sound speed. Individual flow channels are associated with tiny upflows of hot gas (sources) at the inner end and downflows (sinks) at the outer end. SOT/Hinode also discovered ``twisting'' motions of penumbral filaments, which may be attributed to the convective nature of the Evershed flow. The Evershed effect may be understood as a natural consequence of thermal convection under a strong, inclined magnetic field. Current penumbral models are discussed in the lights of these new Hinode observations.Comment: To appear in "Magnetic Coupling between the Interior and the Atmosphere of the Sun", eds. S.S. Hasan and R.J. Rutten, Astrophysics and Space Science Proceedings, Springer-Verlag, Heidelberg, Berlin, 200