NHS England: The Learn from Patient Safety Events (LFPSE) service – patient and family discovery report (13 October 2023)

Summary

As part of the development of the new Learn from Patient Safety Events (LFPSE) service, this report from NHS England summarises the outcome of Discovery Phase research which considered how best patients, service users and their families can give their views on safety incidents, for the whole NHS to learn from.

Content

The Learn from Patient Safety Events (LFPSE) service is a new national NHS service for the recording and analysis of patient safety events that occur in healthcare. It is being rolled out to replace the current National Reporting and Learning System (NRLS) and Strategic Executive Information System (StEIS).

LFPSE Patient and Family Discovery

As part of the development of LFPSE, the aim of this Disocvery Phase was to think about how patients, service users and their families can share their experiences of patient safety events (things that go wrong in care) to help the NHS learn and do better. NHS England ran 34 user research sessions as part of this in which they spoke to:

• 9 people who work in providers/integrated care boards (ICBs). 
• 3 people who work in NHS England’s National Patient Safety team.
• 1 person who works in the NHS England Complaints team.
• 21 patients, service users or a member of their family who use the NHS, or care for family members who use the NHS.

They also:

• Used the information from 30 surveys filled in by patients, service users and their families.
• Spoke to 5 patients from a ‘voice of experience’ patient group for disabled patients.

Research findings

• Patients often want to know the outcome of them raising an issue, especially when they have been more seriously harmed. For events with lower levels of harm, many patients feel less strongly about getting feedback.
• There is no one set way of learning from complaints. Sometimes staff find that complaints contain important information about safety, but complaints teams and patient safety teams do not always speak to each other about what they find. Differences between how teams work together on this is mostly due to numbers of staff and the budgets of individual providers.
• Providers say they want to be able to check information from patients before it is shared with the national team for learning.
• Patients and families agree the NRLS eForm is difficult to find. Many do not know it exists.
• While high level data is fed into the LFPSE, because providers do not include patients’ full comments, there is a chance some safety events or other learning could be missed.
• Staff are trained to enter just the facts when recording an incident or event. This means other information on how an incident has affected the patient, such as feelings and environment could be missed. 
• Because there is too much data and not enough time or staff, when it comes to learning both national and local teams focus on the incidents that have caused the most severe harm.

Next steps

NHS England state that they looked at three main options on how patients, service users and their families can share their experiences of patient safety events:

1. A local process where patients fill in a form for their provider.
2. A national form (like the NRLS eForm) which patients complete and send to the national team.
3. A form that is agreed nationally, which patients can fill in on their own or with their provider, and which is shared with the national team and then back to the provider.

The report states that based on this Discovery Phase research they found that option 3 suited most user needs.