This study looks at how the NHS learns from patient safety problems, including when patients have died because of issues in care. The aim is to understand how learning takes place in healthcare organisations, how national policies are put into practice, and how families and staff are involved in these processes.

The research included several parts:
 

• A review of existing theories about how organisations learn and how safety programmes are designed.

• An analysis of existing data about the NHS Learning from Deaths programme.

• Interviews with NHS leaders and family members who were part of the national steering group.

• A detailed case study in one hospital trust, including interviews with senior managers, frontline staff, and a review of relevant hospital documents.

The study used both numbers (to look at patterns) and in-depth analysis of people’s experiences and views. Special software was used to help organise and interpret the interview transcripts and documents.

Families who had lost loved ones due to problems in care were closely involved throughout the project. Their contributions were vital in shaping the research and ensuring that the findings reflect real experiences.

Lead Investigator