Co-designing and testing Learn Together: A restorative learning approach after patient safety incidents  

Why it matters 

Every year, in the English NHS, there are around 10,000 patient safety incidents which result in severe injury or death. As well as the harm this causes to patients and their families, it also results in legal claims which cost the NHS a significant amount of money.

When these incidents are investigated, it can be helpful to involve patients and families in the investigations, to help get to the bottom of what went wrong and why it happened. It also helps to answer any questions that they might have. The problem is that to date, there hasn’t been much guidance or help available for the people who carry out this type of investigation.

This research aimed to develop and test processes that would help guide the involvement of patients and families in incident investigations, to improve the experience of patients and families, and help organisations learn from them.

What we found 

The study team spoke to patients and families, healthcare staff, and people who investigate incidents, about their experience of safety incident investigations. They also looked at policies from NHS trusts.

In some cases, people didn’t understand the reasons why investigations were carried out. While the reasons they were given often involved learning, making improvements, and helping families and patients understand what had happened, they felt that there were other reasons too, like protecting the organisation’s reputation or finding a staff member to blame.

The team identified a new approach to investigations, called ‘restorative learning’. The foundation of this new approach is ten ‘common principles’ that can help people investigating incidents to involve patients and families meaningfully. These principles, and the guidance that developed around them, was designed together with over 50 people, including patients and families, healthcare staff, investigators, and managers.

Common principles

1. Make apologies meaningful
2. Individualise your approach
3. Be sensitive to timing
4. Treat people with respect and compassion
5. Strive for equity
6. Provide guidance and clarity
7. Listen
8. Be collaborative and open
9. Respect humanity
10. Acknowledge subjectivity

The guidance was tested over a period of fifteen months, in 29 investigations. One further small study also looked at investigation effectiveness after a death by suicide, and who should be involved with it.

The stakeholders who were involved gave positive feedback on the practical approach, especially about how it could help organisations to learn and improve. People thought that it might help to reduce the significant and long-lasting experience of compounded harm. Compounded harm is not related to the initial harms experienced, but results from the processes that follow, including investigations, inquiries, and legal proceedings. Sometimes, these harms can feel more significant to patients and families than those due to a patient safety incident.

At the same time, though, involving patients and families in investigations can sometimes be difficult because their needs may differ from what the organisation wants or needs. Taking part in an investigation was found to be emotional and complicated, so clear information was needed to help people understand and take part, guidance which up until this point, was limited.

Investigations after a suicide are seen as different from other types of investigations, and it’s important that families who have lost someone get support, too.

Although the Learn Together guides may support involvement of patients and families, it’s also clear that investigators need to be trained and supported properly to make the guidance work well. The study highlighted that further research was needed, and should explore how people from minoritised groups experience investigations and look for any ways that the approach could be adapted to better include them.

This study was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research Programme (18/10/02; ISRCTN14463242) and supported by the NIHR Yorkshire and Humber Patient Safety Research Collaboration (NIHR YH PSRC). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.