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

References

• Archer, G., & Colhoun, A. (2017). Incident reporting behaviours following the Francis report: A cross-sectional survey. Journal of Evaluation in Clinical Practice, 24(2), 362–368. https://doi.org/10.1111/jep.12849
   PubMed Web of Science ®Google Scholar
• Argyris, C., & Schön, D. (1974). Theory in practice: Increasing professional effectiveness. Josey-Bass.
   Google Scholar
• Atkinson, P., & Coffey, A. (2010). Analysing documentary realities. In D. Silverman (Ed.), Qualitative research: theory, method and practice (pp. 56–77). Sage.
   Google Scholar
• Baker, D. (2016a). Deaths after police contact in England and Wales: The effects of Article 2 of the European Convention on Human Rights on coronial practice. International Journal of Law in Context, 12(2), 162–177. https://doi.org/10.1017/S1744552316000033
   Google Scholar
• Baker, D. (2016b). Researching deaths after police contact: Challenges and solutions. Journal of Criminological Research, Policy and Practice, 2(1), 15–27. https://doi.org/10.1108/JCRPP-08-2015-0036
   Google Scholar
• BBC. (2022). Essex mental health services inquiry probes 1,500 deaths. https://www.bbc.co.uk/news/uk-england-essex-60865519
   Google Scholar
• Bean, P. (1986). Mental disorder and legal control. Cambridge University Press.
   Google Scholar
• Beck, U. (1992). Risk society: towards a new modernity. Sage.
   Google Scholar
• Beck, U. (1995). EcologicAl politics in an age of risk. Polity Press.
   Google Scholar
• Beck, U. (1999). World risk society. Polity Press.
   Google Scholar
• Berghoff, H. (2018). “Organised irresponsibility”? The Siemens corruption scandal of the 1990s and 2000s. Business History, 60(3), 423–445. https://doi.org/10.1080/00076791.2017.1330332
   Web of Science ®Google Scholar
• Bryman, A. (2012). Social research methods (4th edn ed.). Oxford University Press.
   Google Scholar
• Claridge, T., Cook, G., & Hale, R. (2008). Organizational learning and patient safety in the NHS: An exploration of the organizational learning that occurs following a coroner’s report under Rule 43. Clinical Risk, 14(1), 8–13. https://doi.org/10.1258/cr.2007.070001
   Google Scholar
• Coles, D., & Shaw, H. (2012). Learning froM death in custody inquests: A new framework for action and accountability. Russell Press.
   Google Scholar
• CQC. (2022). COVID-19 insight 11: Our data. https://www.cqc.org.uk/publications/major-reports/covid-19-insight-11-our-data
   Google Scholar
• Cummins, I. (2018). Poverty, inequality and social work: The Impact of Neo-Liberalism and austerity politics on welfare provision. Policy Press.
   Google Scholar
• Department of Health. (2000) . An organisation with a memory. The Stationery Office.
   Google Scholar
• Dodds, A., & Kodate, N. (2011). Accountability, organisational learning and risks to patient safety in England: Conflict or compromise? Health, Risk & Society, 13(4), 327–346. https://doi.org/10.1080/13698575.2011.575454
   Web of Science ®Google Scholar
• Eastman, N. (1994). MentaL health law:Civil liberties and the principle of reciprocity. British Medical Journal, 308(6920), 43–45. https://doi.org/10.1136/bmj.308.6920.43
   PubMedGoogle Scholar
• Easton, J. (2020). Death in custody: inquests, Family participation and state Accountability. Emerald.
   Google Scholar
• Edmondson, A., & Moingeon, B. (1998). From organizational learning to the learning organization. Management Learning, 29(1), 5–20. https://doi.org/10.1177/1350507698291001
   Web of Science ®Google Scholar
• EHRC. (2014). Inquiry into non-natural deaths in detention of adults with mental health conditions, 2010-13. Retrieved June 1, 2015, from http://www.equalityhumanrights.com/publication/inquiry-non-natural-deaths-detention-adults-mental-health-conditions-2010%E2%80%9313.
   Google Scholar
• Feindt, P., & Klenschmitt, D. (2011). The BSE crisis in German newspapers: Reframing responsibility. Science as Culture, 20(2), 183–208. https://doi.org/10.1080/09505431.2011.563569
   Web of Science ®Google Scholar
• Ferner, R. E., Ahmad, T., Babatunde, Z., & Cox, A. R. (2019). Preventing future deaths from medicines: Responses to coroners’ concerns in England and Wales. Drug Safety, 42(3), 445–451. https://doi.org/10.1007/s40264-018-0738-z
   PubMed Web of Science ®Google Scholar
• Francis, R. (2013). Report of the Mid Staffordshire NHs foundation trust public inquiry. The Stationery Office.
   Google Scholar
• Galantino, M. (2022). Organised irresponsibility in the post-truth Era: Beck’s legacy in today’s world at risk. Italian Sociological Review, 12(88), 971–990.
   Google Scholar
• Giddens, A. (1999). Risk and responsibility. The Modern Law Review, 62(1), 1–10. https://doi.org/10.1111/1468-2230.00188
   Google Scholar
• Hitchen, T., Ibrahim, J. E., Woolford, M., Bugeja, L., & Ranson, D. (2017). Premature and preventable deaths in frail, older people: A new perspective. Ageing & Society, 37(8), 1531–1542. https://doi.org/10.1017/S0144686X16000428
   Web of Science ®Google Scholar
• INQUEST. (2015). Deaths in Mental Health Detention: An investigation framework fit for purpose? https://www.inquest.org.uk/Handlers/Download.ashx?IDMF=92fa356f-8335-4c6a-a273-62aad802284c
   Google Scholar
• Kewell, B. (2007). Linking risk and reputation: A research agenda and methodological analysis. Risk Management, 9(4), 238–254. https://doi.org/10.1057/palgrave.rm.8250029
   Google Scholar
• Lalani, M., Bussu, S., & Marshall, M. (2020). Understanding integrated care at the frontline using organisational learning theory: A participatory evaluation of multi-professional teams in East London. Social Science and Medicine, 262, 113254. https://doi.org/10.1016/j.socscimed.2020.113254
   PubMed Web of Science ®Google Scholar
• Leary, A., Bushe, D., Oldman, C., Lawler, J., & Punshon, G. (2020). A thematic analysis of the prevention of future deaths reports in healthcare from HM coroners in England and Wales 2016-2019. Journal of Patient Safety and Risk Management, 26(1), 14–21. https://doi.org/10.1177/2516043521992651
   Google Scholar
• Lupton, D. (1993). Risk as moral danger: The social and political functions of risk discourse in public health. International Journal of Health Services, 23(3), 425–435. https://doi.org/10.2190/16AY-E2GC-DFLD-51X2
   PubMed Web of Science ®Google Scholar
• Mazars. (2015). Independent review of deaths of people with a learning disability or mental health problem in contact with southern health NHS foundation Trust: April 2011 to March 2015. Retrieved January 29, 2020, from https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf.
   Google Scholar
• Mills, C. W. (1956). The power elite. Oxford University Press.
   Google Scholar
• Moore, J. (2016). Coroners’ recommendations and the promise of saved lives. Edward Elgar.
   Google Scholar
• Mythen, G. (2005). From ‘Goods’ to ‘Bads’? Revisiting the political economy of risk. Sociological Research Online, 10(3), 191–203. https://doi.org/10.5153/sro.1140
   Web of Science ®Google Scholar
• Mythen, G. (2018). Thinking with Ulrich Beck: Security, terrorism and transformation. Journal of Risk Research, 21(1), 17–28. https://doi.org/10.1080/13669877.2017.1362028
   Web of Science ®Google Scholar
• National Quality Board. (2017). National Guidance on Learning from Deaths. https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf
   Google Scholar
• NHS. (2016). Five Year Forward View For Mental Health. Available at: https://www.england.nhs.uk/wp-content/uploads/2016/02/Mental-Health-Taskforce-FYFV-final.pdf
   Google Scholar
• NHS. (2019). The NHS Long Term Plan. Available at: https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
   Google Scholar
• NHS England. (2015). Serious Incident Framework: Supporting learning to prevent recurrence. https://www.england.nhs.uk/patient-safety/serious-incident-framework/
   Google Scholar
• NHS Resolution. (2018). Learning from suicide-related claims: A thematic review of NHS Resolution data. https://resolution.nhs.uk/resources/learning-from-suicide-related-claims/
   Google Scholar
• Nuño-Solinís, R. (2017). Revisiting organisational learning in integrated Care. International Journal of Integrated Care, 17(4), 1–6. https://doi.org/10.5334/ijic.3047
   Google Scholar
• Pelfrey, W. V., & Covington, M. W. (2007). Deaths in custody: The utility of data collected from county Coroners. Criminal Justice Studies, 20(1), 65–78. https://doi.org/10.1080/14786010701241358
   Google Scholar
• Porter, E. (2013). Indigenous deaths associated with police contact in Australia: Event stages and lessons for prevention. Australia & New Zealand Journal of Criminology, 46(2), 178–199. https://doi.org/10.1177/0004865813483294
   Web of Science ®Google Scholar
• Powell, M. (2019). Learning from NHS inquiries: Comparing the recommendations of the Ely, Bristol and Mid Staffordshire inquiries. The Political Quarterly, 90(2), 229–237. https://doi.org/10.1111/1467-923X.12697
   Web of Science ®Google Scholar
• Prior, L. (1989). The social organization of death. St Martin’s Press.
   Google Scholar
• Rothstein, H. (2006). The institutional origins of risk: A new agenda for risk research. Health, Risk & Society, 8(3), 215–221. https://doi.org/10.1080/13698570600871646
   Web of Science ®Google Scholar
• Ryan, S. (2019). NHS inquiries and investigations; an exemplar in peculiarity and assumption. The Political Quarterly, 90(2), 224–228. https://doi.org/10.1111/1467-923X.12703
   Web of Science ®Google Scholar
• Salib, E., & Green, L. (2003). Gender in elderly suicide: Analysis of coroners inquests of 200 cases of elderly suicide in Cheshire 1989-2001. International Journal of Geriatric Psychiatry, 18(12), 1082–1087. https://doi.org/10.1002/gps.1012
   PubMed Web of Science ®Google Scholar
• Salleh, A. (2006). ‘Organised irresponsibility’: Contradictions in the Australian government’s strategy for GM regulation. Environmental Politics, 15(3), 399–416. https://doi.org/10.1080/09644010600627717
   Web of Science ®Google Scholar
• Sheaff, R., & Pilgrim, D. (2006). Can learning organisations survive in the newer NHS? Implementation Science, 1(27), 1–11. https://doi.org/10.1186/1748-5908-1-27
   Google Scholar
• Speed, C. (2018). Secrecy and Denial in Matters of Life and Death: A Critical Analysis of Deaths in Psychiatric Detention, 1845-2018 [ Doctoral dissertation, Liverpool John Moores University]. https://researchonline.ljmu.ac.uk/id/eprint/10244/1/2019SpeedPhD1.pdf
   Google Scholar
• Straub, A. (2021). “Natural disasters don’t kill people, governments kill people: ” hurricane Maria, Puerto Rico–recreancy, and ‘risk society’. Natural Hazards, 105(2), 1603–1621. https://doi.org/10.1007/s11069-020-04368-z
   Web of Science ®Google Scholar
• Sutherland, G., Kemp, C., Bugeja, L., Sewell, G., Pirkis, J., & Studdert, D. (2014). What happens to coroners’ recommendations for improving public health and safety? Organisational responses under a mandatory response regime in Victoria, Australia. BMC Public Health, 14(1), 732. https://doi.org/10.1186/1471-2458-14-732
   PubMedGoogle Scholar
• The Patients Association. (2020). Pandemic patient experience: UK patient experience of health, care and other support during the COVID-19 pandemic. https://www.patients-association.org.uk/Handlers/Download.ashx?IDMF=2fdaa424-8248-4743-a4d5-fe1d3f403d20
   Google Scholar
• Thomas, L., Straw, A., & Friedman, D. (2014). Inquests: A practitioner’s guide (2nd edn ed.). Legal Action Group.
   Google Scholar