What is the challenge your project is going to address and how does it connect to your chosen theme?

Since the National Guidance on Learning from Deaths was published in March 2017 provider trusts have been working to implement the Learning from Deaths programme, reporting learning and actions taken from review and/or investigations in their quality accounts. While common insights and learning themes, such as ‘problems in recognising or escalating deteriorating patients’ can be found in quality accounts, the actions and improvements undertaken by trusts are wide-ranging. Evidence that individual provider trusts are accessibly sharing this learning outside of their own organisations other than in the quality account is lacking.

By sharing learning and successful actions undertaken by individual provider trusts, it will be possible for other healthcare providers (primary care, secondary care and ambulance trusts) to gain insights into the processes undertaken, enabling spread of improvements across organisations to improve future patient safety.

What does your project aim to achieve?

• This project will collate and distil the insights from the 200+ provider trusts quality accounts and combine this information with input from members of the Q community about successful, evaluated ‘Learning from Deaths’ actions and improvements within their trusts.
• This project will use a multimedia (an annual ‘Learning from Deaths: sharing insights across boundaries’ report, podcasts, video) approach to sharing this information to the Q community, the wider healthcare community and to the public.

How will the project be delivered?

I am currently undertaking an MD at University College London which involves an evaluation of the impact for the Learning from Deaths programme. As part of this evaluation I have reviewed, collated and analysed all 200+ provider trust quality accounts. I have gained a great deal of insights in improving patient safety from reviewing the quality accounts and feel that the useful information should be available in one place to other clinicians and to the public.

Where I have found significant positive actions from learning in the trust quality accounts I will approach the trust’s patient safety team or equivalent for further details. This information will form the written/audio and video reports.

As part of my research I have formed a public and relatives steering group who are involved in the planning, design and analysis of this study.

By including evaluated actions undertaken by provider trusts we will reduce the risk of promoting actions with low or no impact on patient safety.

What and how is your project going to share learning throughout?

Sharing learning is the overall aim of this project. Podcasts, video casts and the annual written report will be made available to Q community members and the wider system.

Podcasts and videos will be released to the public as they are made.

A regular blog will be written by the team on the Q community website on a bimonthly basis to share the development of the project as well as valuable learning gained from provider trusts Learning from Deaths programmes.