Abstract

This article examines how deaths related to mental health in England and Wales are investigated and the extent to which lessons are learned in their aftermath. It uses two concepts from academic literature to discuss organisational responses to these deaths: organisational learning, and organised irresponsibility. Organisational learning stresses the importance of learning lessons from data; in contrast, Beck’s concept of organised irresponsibility states that organisational lesson learning is impeded by the fragmented and risk-averse nature of public institutions. The article considers 210 organisational responses to Reports to Prevent Future Deaths (PFDs) issued by Coroners. PFDs are sent to any organisation Coroners believe could act to prevent future deaths. The article identifies three findings: Firstly, organisations tend to produce generic responses rather than addressing specific issues raised by Coroners. Second, organisations tend to cite existing policies as responses to Coroners despite those policies not preventing specific deaths. Third, institutions seek to displace blame onto other organisations in attempting to avoid accepting responsibility for the death. The article adds to the canon of knowledge on deaths in healthcare, and in the care of the state by identifying significant structural weaknesses that impede organisational lesson learning about preventable deaths.

摘要

本文探讨了英格兰和威尔士与心理健康相关的死亡事件是如何调查的，以及事件发生后吸取教训的程度。它使用学术文献中的两个概念来讨论组织对这些死亡的反应：组织学习和有组织的不负责任。组织学习强调从数据中吸取教训的重要性；相比之下，贝克的有组织不责任概念指出，公共机构的分散性和规避风险的性质阻碍了组织的教训学习。本文考虑了 210 份组织对验尸官发布的预防未来死亡报告 (PFD) 的回应。PFD 会发送给验尸官认为可以采取行动防止未来死亡的任何组织。文章指出了三个发现：首先，组织倾向于做出一般性回应，而不是解决验尸官提出的具体问题。其次，组织倾向于引用现有政策作为对验尸官的回应，尽管这些政策并不能预防特定的死亡。第三，各机构试图将责任推卸给其他组织，试图避免承担死亡责任。这篇文章通过识别阻碍组织学习可预防死亡的重大结构性弱点，增加了医疗保健和国家护理领域死亡知识的经典。一些机构试图将责任推卸给其他组织，试图避免承担死亡责任。这篇文章通过识别阻碍组织学习可预防死亡的重大结构性弱点，增加了医疗保健和国家护理领域死亡知识的经典。一些机构试图将责任推卸给其他组织，试图避免承担死亡责任。这篇文章通过识别阻碍组织学习可预防死亡的重大结构性弱点，增加了医疗保健和国家护理领域死亡知识的经典。