What is the learning hub?

Anticipated Outcomes

• Mechanisms and processes are in place to support a culture of openness and transparency across key agencies when a death in custody or a patient safety incident occurs
• Common protocols following a death in custody are established, between His Majesty’s Prison and Probation Service (HMPPS), NHS England London Region, and prison healthcare providers
• There is effective collection and management of a database around deaths and patient safety incidents and the provision of thematic analysis across the system
• New approaches to system learning and good practice following a death in custody or a patient safety incident are shared widely across the London Health and Justice system and changes in practice are evidenced through use of qualitative and quantitative data
• Areas of good practice are identified and shared

This work is led by the HJLH Core Team and directed by a Steering Group made up of key stakeholders. Our work began with a focus on deaths in prison but the remit is to develop into broader consideration of patient safety incidents and the wider criminal justice system.

Ethos and Approach

In all our work we aim to develop a culture of curiosity and learning. We have no investigatory or assurance role and will not be investigating incidents or the conduct of individuals or organisations in relation to specific cases. Instead, we aim to provide a facilitative, reflective and psychologically safe approach which encourages multi-agency, pan-system collaboration and the embedding of changes that save lives.

We want to impact culture by modelling and promoting consideration of human factors and relational approaches over processes and embedding the importance of a reflective learning culture.

We are very aware that the work means focusing on the deaths of people in prison and that this is a distressing and sensitive area. We will always hold those individuals and their families at the core of our work. We understand from families of those who have died in custody that they often feel passionate about organisations really learning and changing as a result of the death of their loved ones and we aim to improve learning opportunities and culture so that important lessons are understood, shared and embedded.

We know that this area can also be difficult and distressing for staff who have been involved in caring for those who have died. We will maintain a sensitive approach, focused on curiosity, improvement and saving lives.