Why inquiries are necessary

Editor–There was much good sense in Nigel Eastman's article criticising the current guidance on mandatory inquiries after homicides by psychiatric patients.1 Systematic internal audit should surely follow all serious untoward incidents whether or not an independent inquiry is to be held.

Independent inquiries are established primarily, however, at the request of bereaved relatives or because of grave public or media concern. They also provide explanations for the mentally ill person's family, who may feel guilty as well as let down by health or social services for a failure, as they see it, to provide sufficient protective care. Protests that psychiatrists and other professionals are exposed unfairly to public criticism merely serve to fuel the suspicion, however ill founded, that professionals prefer to keep their working practices hidden from scrutiny.

There is much to be learnt about the most cost effective way to conduct inquiries. Not all require lawyers, although the panel must have expertise in applying the principles of natural justice and fairness. Lingham and I have proposed a timely, economical, and fair process which we believe meets many of Eastman's criticisms but retains the important element of independence usually felt to be essential by relatives and the general public.2

Confidential inquiry is best

Editor–We share Nigel Eastman's concern about the proliferation of individual inquiries after homicides by people with mental illness,1 but we are less convinced that an audit of mental health services in general would be an adequate substitute. Although audit could identify important service omissions, it could not be assumed that there was any link between such omissions and the risk of homicide.

We prefer Eastman's other suggestion, that a modified national confidential inquiry into suicide and homicide by people with mental illness could be of considerable benefit. Since the inquiry relocated to Manchester earlier this year its aims and methods have been overhauled.2 We have now established a data collection system that draws on information from the Home Office's homicide index, psychiatric reports held by courts, and mental health teams. As a result we will collect some information on all homicides, including mental state at the time of the homicide and detailed information about contact with services by those who have been seen by mental health services at any time.

We shall therefore be able to compare psychiatric and non-psychiatric homicides and to examine the relation between psychiatric illness and homicide, regardless of contact with mental health services. In particular, we shall study the process of risk assessment in cases in which contact with services has occurred and chart the sequence of events, including violent incidents, that eventually led to tragedy. This would present opportunities for prevention.

Once we have information on possible indicators of risk and have recommended how services should intervene, we can then conduct an audit of all services, confident that specific omissions in specified circumstances are not only undesirable but dangerous.