In health and social care we are exhorted to continually reflect on our own development and to learn lessons from our experiences and the feedback we receive from others. Reflection is an important tool in personal development and in supporting the development of others through methods such as supervision (Esterhuizen, 2022).
The fundamental point of reflection is that we learn from experiences and consider how to approach similar situations in the future. This learning applies to both positive feedback, things we might do more of in the future,and negative feedback, those things we need to change or do less of.
Reflection, and the learning of lessons, is an important tool therefore in both our personal and professional lives. If we do not reflect and learn then we are condemned to a life of making the same mistakes over and over again.
In this and subsequent articles in this mini-series, we will consider the nature of learning lessons as a leader or manager, and the various ways in which feedback comes to managers and leaders and how that feedback might be reflected upon, lessons learned and ultimately shared with the wider team.
Why lesson learning is important
We have already alluded to the main reason that learning lessons is important in a health or social care environment, which is the avoidance of repeating mistakes, but that is only a part of the picture. Many leaders forget that lessons can be learnt from positive events and feedback and that these are as important in shaping the delivery of care as are errors, omissions and complaints. But why is learning lessons important?
Teams that learn together and adapt their care develop and grow. They create environments which are open and honest and cultures of care which are open to development and the adoption of evidence in its many forms. People’s experiences of care, both patients and professionals, are an important element of evidence-based practice (Ellis, 2023) and so gathering feedback is important. Teams which use evidential care practices do the best for their patients and service users and provide the best care.
Learning lessons is also crucial for patient safety. The Care Quality Commission (CQC, 2025a) in one of their quality statements, identify how they expect providers of health and social care to “have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices”. Such cultures, the CQC theorise, contribute to the safety and wellbeing of patients and service users.
Where feedback comes from
Many managers and leaders think that the only feedback they need to consider in learning lessons is that which arises because of complaints about errors and mistakes affecting patients and service users. They are wrong. A positive comment whether verbal or written is as valuable a form of feedback as is a complaint or negative comment because it tells managers what people consider is going right in their care.
In health and social care, feedback can take a variety of forms both formal and informal, may be verbal or written, may be in response to a request for feedback or may be spontaneous. Some feedback is obviously feedback (such as to a survey), while other feedback is less obviously so (such as a comment made to staff). It is important to note however that a comment made to a staff member is as valuable a form of feedback as a story left on an online feedback forum or in response to a patient survey.
Managers and leaders should also accept that feedback can be negative, neutral or positive. Just because someone is “satisfied” with their care, does not mean they are not leaving feedback and that a lesson cannot be learnt for this. For example, consistent feedback that patients are “satisfied” says that the provision is good enough, but lessons might be learnt from a similar service which is receiving more positive feedback. Feedback may come from a variety of sources including from:
families and friends of patients/service users, staff, colleagues from other departments, and visiting professionals.
The CQC (2025b), as part of their Single Assessment Framework also identify in their ‘Evidence Categories’ how feedback about a service might also come from observation and outcomes. In the case of the CQC, this means their observation of care provision and judgements about the outcomes of care as compared to individuals care and support plans. Managers and leaders might also seek feedback on the care their teams are providing through audits and observation of practice.
From this description it can be seen that gaining feedback is about being open to a host of valuable sources of information which take many forms. It is also clear that these sources are different so the leader or manager must learn to reflect on an amalgam of information in order learn lessons.
What happens when feedback is ignored?
When people working in health and social care ignore feedback bad things can happen to some of the most ‘at risk’ individuals in society. One of the features of many healthcare tragedies in the UK has been that feedback has been ignored.
For example Dr Bolsin, raised concerns about the high mortality rate among paediatric heart surgery patients at Bristol Royal Infirmary in 1990 (The Bristol Royal Infirmary Inquiry, 2001) and was ignored. A fellow GP had raised concerns about Dr Harold Shipman but was not listened to (The National Archives, 2005). Senior doctors had raised concerns about the high death rate in the neonatal unit at the Countess of Chester Hospital, where Lucy Letby worked, but were ignored by management (Halliday et al, 2023).
In these cases ignoring the feedback meant more harm occurred than needed to, but the failure of the healthcare systems, and people within those systems, to learn lessons meant the issues are perpetuated.
The Winterbourne View report (Department of Health, 2012) identified how “staff whose job was to care for and help people instead routinely mistreated and abused them. Its management allowed a culture of abuse to flourish. Warning signs were not picked up or acted on by health or local authorities, and concerns raised by a whistleblower went unheeded.” Notably, even after these now notorious events at Winterbourne View, the BBC found similar patterns of abuse at Whorlton Hall (Plomin, 2019). Failing to learn the lessons of Winterbourne View, meant ‘at risk’ adults were subjected to verbal abuse, as well as being unnecessarily physically restrained at Whorlton Hall.
Similar to all of the above, the Francis Report (2013) into the failings at the Mid-Staffordshire NHS Foundation Trust found that there were systemic failures in the Trust which had a poor culture which meant individuals at all levels of the organisation failed to listen to people who were raising concerns.
All of the scandals mentioned here might have been lessened or averted had someone listened to the concerns being raised and if the lessons arising from previous scandals had been learnt. This suggests the need not only for individual team or organisational learning, but that in health and social care lessons need to be learnt, shared and assimilated at a system level.
What is notable about every one of these cases is that there are in essence two scandals taking place, the first being the abuse, the poor-quality care, the killing of patients, and the second being the failure to act when issues are raised. Small acts of failing to listen and learn lessons can become big issues very quickly
Leaders, managers and health and social care professionals who fail to listen to feedback, fail to act and in so doing perpetuate ill treatment are failing to learn and failing to help their teams and organisations learn.
Conclusion
This article has set the scene for a short series of papers about learning lessons from all sources of feedback in the health and social care setting. It has identified how the learning of lessons is important in the avoidance of repeating mistakes and has given examples of when this has not happened at the organisational and system level.
We have seen how feedback, which is used in the learning of lessons, comes in a variety of forms, as well as from a number of different sources. We have identified something of the role that patients, families, staff and other professionals play in providing feedback. We have further identified how this feedback contributes to a complex web of information which the leader or manager needs to learn to negotiate, reflect upon and from which lessons need to be learnt.
In the subsequent papers in this series we will consider how lessons can be extracted from feedback, how the leader can, with their team, reflect on this feedback and how they then go on to share the learning within and externally to the team.
