Organizational learning and patient safety in the NHS: an exploration of the organizational learning that occurs following a coroner's report under Rule 43

Abstract

Abstract

Patient safety is enhanced by harnessing multiple sources of data, including sources external to the organization – such as the coroner. Following an inquest, the coroner can make a report under the Coroner's Rule 43 to any statutory body or organization when it is identified at inquest that similar fatalities could be prevented if lessons are learnt from the findings of the inquest. An exploratory study was undertaken, using qualitative methodology to investigate the characteristics of organizational learning following recommendations of the coroner under Rule 43 in one district health economy. The role of the coroner was not clear even to the most senior interviewees. There was little evidence of organizational learning generated or shared in the organizations involved in this study from the recommendation of the coroner after a comiogenic (iatrogenic) death. There was evidence of a lack of clarity in both structure and function in the handling of and learning from coroner's recommendations both within and between the organizations involved in this study. The role of Rule 43 reports should be explored at national level and standardized tools developed in order to facilitate learning within and between NHS organizations.