Organisational learning, or organised irresponsibility? Risk, opacity and lesson learning about mental health related deaths

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.