'Diffusion of responsibility' begets domino blame and history repeats itself
I've thought for a while that the outcomes of high profile investigations in health and social care can feel clichéd. "Communication" is invariably the predominant failing and we repeatedly "learn" that communication between agencies needs to improve. The terribly-bad-thing that happened actually might not happen again if we just learn this lesson...except we never do.
Over and over the same failings lead to the same horrendous outcomes and history repeats itself.
There will be an investigation into my brother's death and it will lead to a list of 'lessons learnt'. No doubt these will be a strikingly familiar list, regurgitated once again like in many cases before. Why are these 'lessons' so rarely translated into meaningful changes in practice?
People with Learning Disabilities are often supported by a wide number of people. Different professionals in different agencies in different premises. Diverse knowledge and skills are then available but does this lead to 'diffusion of responsibility', wherein everyone assumes someone else will take responsibility?
I don't think the stuff my brother needed was rocket science but it feels like nobody stepped up to the task or had the 'whole person' in mind. When it came to his physical health, perhaps everybody thought somebody else had it covered?!
The question on everybody's lips after a preventable death should be: "what could we have done?", "why didn't we do it?", "what got in our way?" and "what do we need in order to really change?". Instead the dialogue within investigations can be more akin to "it wasn't our job", "that other agency is to blame" and "someone else should have, would have, could have...".
They blame me, I blame you, you blame the others and a domino effect seems to emerge...diffusion of responsibility begets domino blame and history repeats itself.
Unless we recognise and revise this habit, people with Learning Disabilities will continue to die young with preventable illnesses that are amenable to treatment. We have known this is happening for around 40 years yet the death toll rises; we are clearly not “learning lessons”.
How much longer should we stand by and let this happen before we make serious changes? When will we commit to really "learning" when things go wrong?! And with our complex health and social care system with multiple 'leaders', how do we overcome diffusion of responsibility and domino blame, which currently seem to jeopardise any attempts at real change?
I don’t have the answers but I hope that asking the question is a start.
This poem comes to mind:
That's Not My Job!
Once upon a time, there were four people...
Their names were Everybody, Somebody, Nobody and Anybody.
Whenever there was an important job to be done,
Everybody was sure that Somebody would do it.
Anybody could have done it, but Nobody did it.
When Nobody did it, Everybody got angry because...
it was Everybody's job!
Everybody thought that Somebody would do it,
but Nobody realised that Nobody would do it.
So, consequently, Everybody blamed Somebody...
when Nobody did what Anybody could have done in the first place!