The recent news that Southern Health NHS Trust apparently failed to properly investigate over 1,000 unexpected patient deaths is a shocking direct failure of basic responsibility to the bereaved families.

There is a second, indirect failure affecting every person entitled to healthcare from Southern Health.  In failing to investigate these unexpected deaths, Southern Health has missed the opportunity to learn from any errors made, missing the potential to improve outcome for every taxpayer dependent on the Trust for healthcare services.

It also raises another question for me.  Presumably there are a much larger number of non-fatal unexpectedly adverse outcomes experienced by Southern Health and indeed all NHS Trusts.  What, in terms of management systems and more importantly leadership and culture, are Trusts doing to learn from their mistakes and near misses?  Is there a much wider missed opportunity and learning failure here than Southern Health alone?

Accepting that failures and near-misses will occur in even the best-led and best-operated organisations is a critical cultural asset. Recognising and learning from mistakes has been shown to be one of the most powerful learning tools we have, and is a key differentiator in driving health and safety improvements across industry sectors.  In this context Matthew Syed’s book “Black Box Thinking” is well worth reading.

NHS England has expressed shock at the Southern Health draft report findings; perhaps this shock will prompt a more wide-ranging review of how medical services providers and practitioners recognise, review and learn from mistakes and near-misses.

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