Qualitative Analysis of Recommendations in 79 Inquiries after Homicide Committed by Persons with Mental Illness

Melissa McGrath MA* and Femi Oyebode FRCPsych**

‘Building a Safer NHS for Patients’(1) proposes significant changes to the reporting of adverse eventsin Britain’s healthcare system including the place of inquiries in the analysis of adverse events. Within mental health services, since 1994 an independent inquiry has been mandatory for all homicides committed by persons in contact with mental health services. The inquiry reviews thecare the patient was receiving at the time of the incident, the suitability of that care with regard to the patients history, health and social care needs, and the extent to which the care corresponded with statutory obligations of the health service.2A report is usually published following each inquiry including a set of recommendations based on the findings of the inquiry. The assumption is that these recommendations are intended to influence mental health policy and practice. However, many critics argue that inquiry reports and their recommendations have yet to substantially alter policy and practice.3,4

Footnotes:
*Ms Melissa McGrath is a Research Assistant at the South Birmingham Mental Health NHS Trust and a Postgraduate student in Psychology at the University of Birmingham.
**Professor Femi Oyebode is a Consultant Psychiatrist and Director of Research & Development for the South Birmingham Mental Health NHS Trust, Head of the Department of Psychiatry at the University of Birmingham, and Chief Examiner for the Royal College of Psychiatrists.
(1) Department of Health (2001). Building a Safer NHS for Patients: Implementing Organisation with a Memory. London: DOH.
(2) Department of Health (1994). Guidance on the discharge of mentally disordered people and their continuing care in the community. HSG (94)27.London: NHS Executive.
(3) Eastman, N. (1996). Inquiry into homicides by psychiatric patients: systematic audit should replace mandatory inquiries. British Medical Journal, 313,1069–71.
(4) Crichton, J. & Sheppard, D. (1996). Psychiatric Inquiries: Learning the Lessons. In Peay, J. (ed.) Inquiries after Homicide. Duckworth: London.

Price: £3.00

 

<< Back to previous page