Independent inquiries into homicideBMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7191.1089 (Published 24 April 1999) Cite this as: BMJ 1999;318:1089
Should share common methods and be integrated into new quality systems
- Alec Buchanan, Clinical senior lecturer in forensic psychiatry.
Since 1994 an independent inquiry has been required in all cases of homicide by discharged psychiatric patients in England and Wales.1 Psychiatrists have argued that these inquiries are inefficient, costly, misleading, and potentially unjust, yet their suggestions that they should cease, or be incorporated into other forms of audit,2 have not been adopted. Inquiries undoubtedly serve some important needs, but their failure to ask a consistent set of questions or develop a common methodology has limited their usefulness.3 In particular, many inquiries have not recognised the limitations inherent in the study of a single case.
Inquiries are important because they help relatives to find out what happened. Both relatives and the public want to know that everything that should have been done was done: they wish to see addressed the prima facie case that if someone is dead care must have been inadequate. Moroever, there is a widespread view, shared by some psychiatrists, that inquiries provide a way of assessing and improving services. But a lack of focus has limited the benefits.
The departments of health for England and Wales recommended some terms of reference for inquiries. Typically these include: the quality and scope of the patient's health care, social care, and risk assessment; the appropriateness of his or her treatment, care, and supervision; the extent to which care met statutory obligations and complied with health department guidance; the appropriateness of staff training and the adequacy of collaboration between the agencies. Faced with this list, it is hardly surprising that different inquiries have concentrated on different questions.
The methods adopted by different inquiries have also been inconsistent. There is no consensus, for instance, on whether hearings should be in private or in public, on whether witnesses should have legal representation, or even on whether consent needs to be obtained before a patient's medical records are used. There is no agreed size or composition for an inquiry team. Members receive no training, although most only ever do one inquiry, and there is no agreed pool from which they are drawn. Crucially, no attempt has been made to address one of the central questions of social science, a question which the very existence of inquiries raises: What can the study of an individual case tell us?
If they are to continue, independent inquiries should sharpen their focus. They should attempt to answer one question and comment on the performance of services in relation to two others. The question they should attempt to answer is: Was there anything that should have been done, but was not done, which would have reduced the chances of a homicide occurring? This question is preferable to one that many attempt to answer at present: Could the homicide have been prevented? This second question requires an explanation of why (not merely how) the homicide happened—and thus raises the question of whether our actions are determined by chains of cause and effect which operate according to laws and, hence, predictably? This has detained philosophers and social scientists for centuries.4 Concentrating on “the chances of a homicide occurring” would avoid the necessity for inquiries to defer to Aristotle.
The two questions where inquiries should limit themselves to commenting are: Were the services meeting accepted standards? and Are those standards good enough? Inquiries should address these two questions because failures of service provision need to be communicated and because the opportunity to discuss whether anything would have helped should not be wasted. When inquiries conclude that all psychiatrists should train in forensic psychiatry, that the law ought to be changed, or that caseloads should be smaller they may be going beyond their present terms of reference. Yet in many ways inquiries are more suited to reflection of this kind than they are to passing judgment on individual decisions. Inquiries should not attempt to provide answers to the two questions because a case study is no way to establish whether standards were generally poor and no inquiry has the authority to make the value judgements which should precede any change in those standards.
Inquiries should use common methods which have been subjected to public, professional, and academic scrutiny. They should employ a limited number of experienced people with relevant expertise. The results would be less time consuming, and easier to understand and compare, and they might be incorporated into research such as the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness.5 When an inquiry observes failures of clinical practice or questions good practice it should refer its findings to a body better suited to the development and application of normative standards.
The proposed National Institute for Clinical Excellence (NICE)—established to draw up guidelines for the management of particular conditions and groups of patients—could act as a secretariat for inquiries and disseminate their findings. When an inquiry identified failures that were serious or repeated, the institute could refer a service to the Commission for Health Improvement, whose job it will be to monitor adherence to NICE guidelines. If independent inquiries can be integrated into procedures designed to improve quality they may be seen by the professions as less persecutory. And when criticisms of individuals or services are made these may more readily be accepted if they are seen as part of a process that improves services.
AB has served on an independent inquiry, set up by Haringey Health Authority.