Suicide Investigations in Adult Community Mental Health Services: Mitigation of the Fear of Blame as a Barrier to Organisational Learning.

Effective suicide prevention strategies in community mental health services demand high standards of patient safety. The nature of suicide is complex and uncertain. However, learning needs to be sensitive to the fear of blame. Little is known about how health services investigate suicides post hoc, how they examine why a suicide might have occurred, and how they generate any organisational learning that might improve patient safety. The aim of this novel qualitative study was to explore the accounts of key people involved in the serious incident investigation process regarding the subsequent organisational learning. Carers, clinicians, investigators and senior managers were recruited via regional and national networks; data were collected through focus groups and individual interviews. The dominant themes that emerged from this analysis did not reflect the tenor of the literature related to the investigative process and organisational learning, accepting that the literature is relatively sparse. A reflexive thematic analysis developed an understanding of mitigations against a fear of blame which appeared protective of all participants' positions, including those specific to suicide risk. We argue that mitigation operated as a barrier to organisational learning and improving patient safety in adult community mental health services. The findings are discussed in the context of organisational culture, learning and wider system thinking. The concept of mitigation against a fear of blame constructs new insights into this ambiguous and emotionally demanding sphere of patient safety.