Learning from Avoidable Harm and Death in Healthcare

June 25, 2020 RLDatix Marketing
In recent years, there has been an increasing recognition that the way in which the NHS investigates and learns from instances of avoidable harm and death is extremely variable and often poor.

This is an issue that has been identified time and time again in major national inquiries, from Sir Ian Kennedy’s report into children’s cardiac surgery at Bristol in 20011, the Mid Staffordshire report in 20132, the Morecambe Bay report in March 20153 and more recently, the Mazars report4, which looked at the deaths of people with learning disabilities who came into contact with the Southern Health trust between April 2011 and March 2015.

The Mazars report was commissioned following the tragic death of 18-year-old Connor Sparrowhawk5. Connor, who had a learning disability and epilepsy, died in 2013 while receiving care at an assessment and treatment centre run by Southern Health NHS Foundation Trust. The report identified serious failings in how the trust recorded and investigated deaths and highlighted that certain groups of patients, including people with a learning disability, were far less likely to have their deaths investigated by the trust.

All of these reports have highlighted major flaws in the way the NHS investigates and learns from mistakes. Yet despite a widespread awareness of the issues and recommendations for improvement going back at least fifteen years, progress has been limited.

In 2001, the recommendations of Sir Ian Kennedy’s report into children’s cardiac surgery at Bristol Royal Infirmary included a duty of candour (openness and honesty with families), a structured approach to investigating serious incidents, closer involvement of families with their children’s care and responding to families’ concerns when things go wrong. In 2016, the Health Service Journal (HSJ) reported on the tragic cases of Sean Turner6 and Luke Jenkins7 who died in 2012 following cardiac surgery at Bristol Royal Infirmary. The Parliamentary and Health Service Ombudsman (PHSO) published investigation reports relating to both cases that found serious failures in care that had not been previously identified or acknowledged. The reports were critical of the way the Bristol trust investigated what happened and responded to the families’ concerns, finding that they did not provide “completely evidence-based open and honest responses”.

This is the sombre context in which we come to the report published by the Care Quality Commission (CQC) last week8, commissioned in response to the findings of the Mazars report which looked at how NHS trusts review and investigate the deaths of patients in England.

The findings of the CQC report include:

  • Families and carers often have a poor experience of NHS investigations and are not consistently treated with respect, sensitivity and honesty.
  • Many carers and families do not find the NHS to be open and transparent.
  • Families and carers are frequently not listened to. In some cases family and carer involvement is tokenistic, despite many trusts stating that they value family involvement.
  • The quality of investigations is variable and inconsistent. This acts as a barrier to identifying opportunities for learning.
  • Following NHS investigations, there are no consistent systems in place to make sure recommendations are acted on or learning is being shared with others who could support the improvements needed.
  • The NHS does not prioritise learning from deaths and misses opportunities to learn and improve as a result.
  • There is no single framework which sets out how local NHS organisations should identify, analyse and learn from deaths of patients in their care or who have recently been in their care.
  • Some NHS trusts get some elements of mortality reporting right, but not one gets all elements right.
  • CQC’s Chief Inspector of Hospitals, Sir Mike Richards9 said “…the extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.”

A new era for patient safety

Last week, the Secretary of State for Health Jeremy Hunt outlined the measures being taken by the government in response to the CQC review10. From April 2017, boards of all NHS trusts and foundation trusts will be required to carry out a range of new responsibilities and actions. These include:

  • Collecting specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned on a regular basis.
  • Publishing information quarterly, in accordance with new regulations, so that local patients and the public can see whether and where progress is being made.
  • Publishing evidence of learning and action‎ that is happening in response.
  • Identifying a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced within their organisation.
  • Following a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided, and learning from mistakes.

The government has also confirmed that new guidelines on reviewing and learning from the care provided to people who die will be published before April 2017. Work is also being done with the National Quality Board to ensure that greater support is offered to bereaved families in the future and Jeremy Hunt has signaled that the way in which families are involved and supported by trusts following deaths will be subject to closer scrutiny by the CQC11.

Given that so many previous reports have made recommendations aimed at addressing the themes echoed by last week’s CQC report, there will be understandable scepticism that meaningful changes will follow. However, there has never before been a time when our knowledge and understanding of the issues, the consequences for the safety of patients and the actions needed to make improvements, has been greater. This time, the NHS simply must rise to the challenge of ensuring that this latest report really does mark a turning point.

At RLDatix, we believe that healthcare organisations in England and globally, are on the cusp of a revolution in their approach to patient safety, learning from things that go wrong and sharing lessons and best practice. New tools and technology12 are set to play an important role in this journey. Individual organisations will need to play their part in ensuring that they have the necessary resources, training, systems and culture in place to ensure that in the future, opportunities to learn from things that go wrong in healthcare are not missed, but instead are properly investigated, staff involved in errors treated fairly within a just culture, families properly involved and supported and contributory factors identified so that sustained strategies and interventions can be put in place, measured and shared to protect future patients from harm.


  • National Archives. The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995.
  • Gov UK. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. 
  • Gov UK. Morecambe Bay Investigation
  • Mazars. Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015. 
  • BBC. Connor Sparrowhawk inquest: Care unit death ‘contributed to by neglect’. 
  • Lintern, Shaun. Exclusive: Trust guilty of serious service failure over child’s death. 
  • Lintern, Shaun. Investigation finds major service failure related to second childs death at hospital. 
  •  CQC. Learning, Candour & Accountability
  • Brennan, Sharon. Mike Richards: Death investigations poor and ‘need an overhaul’. 
  • Department of Health. MP Hunt, Jeremy. CQC review of deaths of NHS patients. 
  • Lintern, Shaun. Hunt: Trusts face poor CQC rating for ignoring families
  • RLDatix. DatixCloudIQ
Previous Article
The Impact of Big Data on Patient Safety
The Impact of Big Data on Patient Safety

Healthcare organisations seem to have an affinity for paper, however executives are discovering that paper ...

Next Article
Implementing the national learning from deaths guidance
Implementing the national learning from deaths guidance

Around 50% of all deaths occur in hospital and while many of these are inevitable, it is estimated that bet...