Academic Journal
Learning from deaths
| Title: | Learning from deaths |
|---|---|
| Authors: | Brummell, Z, Walker, D |
| Source: | Advances in Perioperative Care , 1 (1) pp. 1-5. (2026) |
| Publisher Information: | UCL Press |
| Publication Year: | 2026 |
| Collection: | University College London: UCL Discovery |
| Subject Terms: | avoidable harm, death, inquiry, NCEPOD, ombudsman |
| Description: | This narrative article explores why healthcare systems repeatedly fail to learn from preventable deaths. We present Mrs L, who died less than 6 weeks after routine hip replacement surgery. She had attended preoperative assessment with hypertension and renal impairment, which worsened before surgery. Postoperatively, she became hypotensive and hypoxic overnight, but the senior staff were not informed. She developed multiple organ infarctions, required two further operations and died 3 days later. The Parliamentary and Health Service Ombudsman identified multiple missed opportunities to intervene. This case reflects a persistent problem. Studies show that 5.2% of hospital deaths are preventable, with surgical patients at higher risk. Despite decades of inquiries and reports, the same issues recur: poor clinical monitoring, diagnostic errors and inadequate fluid management. In practice, high-profile investigations rarely translate into frontline learning. The 2017 National Quality Board guidance now requires National Health Service (NHS) Trusts to publicly report on deaths and learning, but real change often comes from bereaved families rather than healthcare systems. Connor Sparrowhawk’s death and the subsequent family campaign exposed widespread failures in death investigation processes. What works? When families like Joshua Titcombe’s and Elaine Bromiley’s drive change, systems actually improve. Their personal stories create experiential learning that statistics cannot achieve. As healthcare professionals, we need both systematic processes for reviewing deaths and personal narratives that make lessons stick. |
| Document Type: | article in journal/newspaper |
| File Description: | text |
| Language: | English |
| Relation: | https://discovery.ucl.ac.uk/id/eprint/10221204/ |
| Availability: | https://discovery.ucl.ac.uk/id/eprint/10221204/1/apoc-3511-brummell.pdf https://discovery.ucl.ac.uk/id/eprint/10221204/ |
| Rights: | open |
| Accession Number: | edsbas.D58032D2 |
| Database: | BASE |
| FullText | Text: Availability: 0 CustomLinks: – Url: https://discovery.ucl.ac.uk/id/eprint/10221204/1/apoc-3511-brummell.pdf# Name: EDS - BASE (ns324271) Category: fullText Text: View record from BASE |
|---|---|
| Header | DbId: edsbas DbLabel: BASE An: edsbas.D58032D2 RelevancyScore: 1011 AccessLevel: 3 PubType: Academic Journal PubTypeId: academicJournal PreciseRelevancyScore: 1010.63568115234 |
| IllustrationInfo | |
| Items | – Name: Title Label: Title Group: Ti Data: Learning from deaths – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Brummell%2C+Z%22">Brummell, Z</searchLink><br /><searchLink fieldCode="AR" term="%22Walker%2C+D%22">Walker, D</searchLink> – Name: TitleSource Label: Source Group: Src Data: Advances in Perioperative Care , 1 (1) pp. 1-5. (2026) – Name: Publisher Label: Publisher Information Group: PubInfo Data: UCL Press – Name: DatePubCY Label: Publication Year Group: Date Data: 2026 – Name: Subset Label: Collection Group: HoldingsInfo Data: University College London: UCL Discovery – Name: Subject Label: Subject Terms Group: Su Data: <searchLink fieldCode="DE" term="%22avoidable+harm%22">avoidable harm</searchLink><br /><searchLink fieldCode="DE" term="%22death%22">death</searchLink><br /><searchLink fieldCode="DE" term="%22inquiry%22">inquiry</searchLink><br /><searchLink fieldCode="DE" term="%22NCEPOD%22">NCEPOD</searchLink><br /><searchLink fieldCode="DE" term="%22ombudsman%22">ombudsman</searchLink> – Name: Abstract Label: Description Group: Ab Data: This narrative article explores why healthcare systems repeatedly fail to learn from preventable deaths. We present Mrs L, who died less than 6 weeks after routine hip replacement surgery. She had attended preoperative assessment with hypertension and renal impairment, which worsened before surgery. Postoperatively, she became hypotensive and hypoxic overnight, but the senior staff were not informed. She developed multiple organ infarctions, required two further operations and died 3 days later. The Parliamentary and Health Service Ombudsman identified multiple missed opportunities to intervene. This case reflects a persistent problem. Studies show that 5.2% of hospital deaths are preventable, with surgical patients at higher risk. Despite decades of inquiries and reports, the same issues recur: poor clinical monitoring, diagnostic errors and inadequate fluid management. In practice, high-profile investigations rarely translate into frontline learning. The 2017 National Quality Board guidance now requires National Health Service (NHS) Trusts to publicly report on deaths and learning, but real change often comes from bereaved families rather than healthcare systems. Connor Sparrowhawk’s death and the subsequent family campaign exposed widespread failures in death investigation processes. What works? When families like Joshua Titcombe’s and Elaine Bromiley’s drive change, systems actually improve. Their personal stories create experiential learning that statistics cannot achieve. As healthcare professionals, we need both systematic processes for reviewing deaths and personal narratives that make lessons stick. – Name: TypeDocument Label: Document Type Group: TypDoc Data: article in journal/newspaper – Name: Format Label: File Description Group: SrcInfo Data: text – Name: Language Label: Language Group: Lang Data: English – Name: NoteTitleSource Label: Relation Group: SrcInfo Data: https://discovery.ucl.ac.uk/id/eprint/10221204/ – Name: URL Label: Availability Group: URL Data: https://discovery.ucl.ac.uk/id/eprint/10221204/1/apoc-3511-brummell.pdf<br />https://discovery.ucl.ac.uk/id/eprint/10221204/ – Name: Copyright Label: Rights Group: Cpyrght Data: open – Name: AN Label: Accession Number Group: ID Data: edsbas.D58032D2 |
| PLink | https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=edsbas&AN=edsbas.D58032D2 |
| RecordInfo | BibRecord: BibEntity: Languages: – Text: English Subjects: – SubjectFull: avoidable harm Type: general – SubjectFull: death Type: general – SubjectFull: inquiry Type: general – SubjectFull: NCEPOD Type: general – SubjectFull: ombudsman Type: general Titles: – TitleFull: Learning from deaths Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Brummell, Z – PersonEntity: Name: NameFull: Walker, D IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2026 Identifiers: – Type: issn-locals Value: edsbas – Type: issn-locals Value: edsbas.oa Titles: – TitleFull: Advances in Perioperative Care , 1 (1) pp. 1-5. (2026 Type: main |
| ResultId | 1 |