Homicide, Suicide and Mental Health: Time for a Rethink?

In the wake of yesterday’s ONS crime statistics revealing a major drop in homicide rates in England and Wales, has the ‘inquiry culture’ made any significant impact on mental health-related tragedies, and is it time for a rethink? 

If you’ve worked in front-line mental health at any time in the last two decades, there’s a small but not insignificant chance an independent inquiry has shone it’s torch at you, your colleagues and your collective role in a homicide.

Yesterday’s announcement suggests a downward trend in homicide rates, but before 2011-2012 there were between five and six hundred and fifty homicides recorded in England each year (National Confidential Inquiry, 2012). On average around ten per cent of these deaths will have been committed by a ‘psychiatric patient’, or to be more precise, by a perpetrator who has been in contact with mental health services within a year prior to the offence.

This relatively small contribution may come as a surprise to the more indignant ends of the media. And it is hardly a damming indictment of community care, especially as only a proportion of ‘psychiatric’ killings will have been committed as a direct result of psychiatric pathology such as command hallucinations or paranoid beliefs.  A mentally ill killer doesn’t necessarily kill for reasons that are different from anyone else.

Nonetheless, this is still fifty or sixty people a year dying at the hands of someone whose name is on the books of a mental health professional, and the question of preventability is one that must be asked.  And it does. Dozens of times a year.

Independent inquiries into mental illness related homicides were made mandatory in the wake of the Ritchie Report of 1994. In the light of criticism about their continued usefulness, not to mention the weighty invoices for an army of psychiatrists , barristers and other senior personnel who make up the panels, the ‘mandatoriness’ was slightly relaxed in 2005, but still we are seeing dozens of publications a year of inquiry reports which were once headline news but are now so common as to be barely noticed.
Homicide is not the only adverse event to trigger independent inquiries. Suicides, sudden unexpected deaths and safeguarding events can all be subject to scrutiny where circumstances dictate, generating what is now a vast library of reports, findings and recommendations. We are all aware of the benefit of hindsight, and there’s certainly no shortage of it here.
 
Lack of communication, inter-agency squabbling, non-adherence to the Care Programme Approach and poor or non-existent discharge procedures are all among the usual suspects to appear within the panel’s cross-hairs. We will also read frequent accounts of agencies such as the police, mental health professionals and social services treating each other as if they had a communicable disease. 

But other themes are also present in abundance. Professional disinterest. A ‘more than my jobs worth, guv’ attitude. Rigid bureaucracy and referral criteria trumping good clinical judgement. Oh, and we nearly forgot a lack of common sense and sheer incompetence.

We should all by now have learnt our lessons. We should have developed evidence-based, multi-agency training in prevention of violence and suicide. We should have developed collaborative approaches to working with crisis and risk involving everyone within a community who works with mental health: Community Mental Health Teams, the Police, Parmamedics and Support Workers. Everyone.

We should have developed collaborative, reflective approaches to analysis of adverse events and ‘near misses’ which involve service users and those so often excluded from deliberations, the families and carers. And we should have developed robust policies and procedures which mean risk work becomes a key clinical skill and not the ticking of a few boxes on a side of A4.
 
But while there is certainly evidence that care providers have followed recommendations at an organisational level, have eighteen years of automatic inquiries really made an impact at the sharp end of care and support? Are inquiry recommendations actually being followed and learnt from in day-to-day practice, or are the reports offering little more than a handsome hourly fee for their very expensive authors?

There is no evidence of any decline in the rate and frequency of homicides, suicides or other adverse events. Suicides are becoming less frequent among in-patients, but is this due to improved care on the wards or to the fact that trusts have followed previous advice from the NCI in removing ligature points such as curtain rails? And why has there been a rise in suicides among patients in ‘home care’? 


The faults highlighted by countless inquiries and repeated here are still happening day in and day out. I don’t need a literature review to know this – I’m a trainer. I see and hear the horror stories from staff all over the UK and from a wide variety of settings. So if these are the problems, where are the solutions?

I have two very simple, affordable suggestions for mental health care which may (if you’ll forgive the drama) save lives.

Firstly I would very strongly support the suggestion that we now abandon the independent inquiry system and hand responsibility for the scrutiny of adverse events to the National Confidential Inquiry. One centrally organised body using standardised methodologies to examine homicides, suicides and sudden unexpected deaths, feeding their work directly into a programme of training and research that directly links evidence with day-to-day reality.

Secondly, I think it’s time for a change in how front-line mental health services work with risk. We’ve seen painful evidence over many years of how the collective will, for a variety of reasons, make mistakes and allow tragedies to occur.

Perhaps it’s time for an individual response. A Risk Practitioner.  Or even, if you prefer the dramatic, a Troubleshooter.

An experienced individual who knows what can happen, has an intimate awareness of the inquiries and evidence base, can coach, micro-teach and work alongside front-line colleagues, and has the ability to link agencies, teams and individuals together  in a way that we seem patently unable to do when left to our own devices.

If this sounds rather fanciful, it’s been done. Unfortunately the very partisan forces that so often plague inter-agency working brought my particular project to a premature close, but as a Forensic CPN I once worked closely with an Assertive Outreach Team fulfilling pretty much the job description outlined above. There was of course a little more to it than that which might have benefitted from formal audit or research, but as proof of concept it worked extremely well.

The tragedy of psychiatric disaster is far more real and important than any number of statistics or findings or recommendations. If even only a few of these events is preventable, then surely we should be sitting up and taking notice of how to do the precenting. Maybe it really is time to try something new. 


This post was written as part of a Risk and Mental Health project currently in preparation by the author

The Occasional Tragedy of Mental Health


A Problem of Understanding
I used to work with people who had committed the most serious and often disturbing of crimes. All in all I spent twelve years in very close proximity to patients in secure psychiatric units. I played cards with killers, badminton with rapists and darts with men you had last seen played by an actor on Crimewatch.

I’ve been shopping with people who hadn’t seen a town centre for twenty years. I’ve handed out tissues to those still haunted by what they had done, and locked up patients in small secure rooms as the voices commanded them to kill anyone within range of a pool cue.

I’ve had the sort of conversations you could and should never forget with fellow human beings who have done unimaginable things. But one thing I have never done is to understand.

Not for want of trying or because I wasn’t clever enough. I ‘got’ the psychopathology of the psychopath. I ‘got’ the biochemistry of psychosis. I ‘got’ the medical model and the social model. But faced with someone who had tortured a child, blown off a neighbours head with a shotgun, or knocked nails into someone’s skull, I simply failed to truly understand.

Thirteen-year old Casey Kearney was walking through a park on her way to a friend’s. She was stabbed by a woman walking in the opposite direction. It wasn’t a frenzied attack, just one brief blow with a one of two kitchen knives purchased earlier that day by a woman called Hannah Bonser, who simply continued on her way before turning up at a local mental health resource to confess to what she called “a silly thing” and hand over her knives.

This was an appallingly random act of extreme violence. Bonser would have expended more time and energy stopping to ask her victim for the time. For any parent to imagine the deliberate killing of a child is not only incomprehensible, but entirely unimaginable for any more than the most fleeting of dark moments. But Casey Kearney’s family have had to deal with this reality since February 14 this year, and have no doubt tried and failed to make sense of the senseless.

Making Sense of the Senseless
Hannah Bonser was yesterday convicted of murder and sentenced to life imprisonment. She will serve an absolute minimum of twenty-two years before being able to seek parole. Those not involved with the case might have been surprised that Bonser did not receive a Mental Health Act hospital order and a conviction for Manslaughter rather than Murder.

After all, this was a bizarre and random killing committed by someone well-known to mental health services for some time before the event. Her legal defence argued she was suffering from Paranoid Schizophrenia at the time of the offence, and that her responsibility for the crime was therefore ‘diminished.’ The jury did not accept this argument.

But as with all homicides involving mental health service users, an independent inquiry will now take place in the aftermath of the trial. Like the dozens that have preceded it since the mid-1990s (when such inquiries became mandatory) the report will provide a public and detailed account of Bonser’s relationship with mental health services in the months and years prior to February 14th 2012.

As both a practitioner and trainer who has read with depressing regularity how tragedy has resulted from the failure of various services involved in mental health care over the years, I very much hope we will not be hearing from the usual suspects. Failures of communication, lack of information sharing, poorly motivated professionals, bureaucracy. All these and more have become depressingly familiar to readers of such reports, but seldom appear to change the way we work with potentially dangerous people.

What’s in a Diagnosis?
For some months prior to the killing, a close friend of Hannah Bonser had noted how her behaviour had become increasingly unusual. She claimed that her flat was possessed by demons. Her self-care deteriorated and she travelled down to London, where she slept rough and searched for a character called ‘Simon of Lambeth’. She was detained under the Mental Health Act before being transferred back to a Doncaster hospital, but was discharged shortly afterwards. Life appears to have become increasingly disjointed and chaotic. Shortly before Casey’s death, her killer had presented to mental health staff stating she was hearing voices commanding her to harm others.

Her legal defence was that her actions were driven by severe mental illness. It’s well beyond the scope of a short blog post to attempt to describe what we mean by this, but on current evidence we could state the following. That at the time of the offence her brain was showing signs of abnormal structural and biochemical functioning and was interacting with an environment which to Hannah Bonser would be a very, very different place to how most of you reading this would experience that environment. It may have been quite a terrifying place. Perhaps terrifying enough to randomly stab a complete stranger.

The prosecution argued that Bonser was not psychotic but suffered from a Personality Disorder. We know even less about the inner workings of PD than Schizophrenia, and argue about it a great deal more. This diagnosis would imply that the person is fully aware of one’s actions and knows exactly what they are doing, even when what they are doing is indescribably unpleasant.

The Sadness of Madness v Badness
The difference between severe mental illness and personality disorder is characterised by some as the ‘mad versus bad’ dichotomy. This is a very false dichotomy. In fact, it’s not a dichotomy at all.  The opposite of ‘mad’ is ‘sane’ and the opposite of bad is of course ‘good’. It’s an old and rather stale argument often used by lazy mental health professionals to characterise the difference between behaviours which are driven by ‘genuine’ and ‘proper’ mental illness on the one hand, and behaviours which are apparently ‘manipulative’ or ‘attention seeking’ on the other.

Being ‘Mad’ is beyond both the conscious control of the sufferer, and the moral judgement of others. It warrants our intervention, diagnosis and treatment, particularly with pharmacological means which offer a quick and relatively simple solution to ‘Mad.’

But ‘Bad’ is just, well, bad. If it isn’t ‘Mad’, isn’t a psychiatric problem, we needn’t offer an intervention. Personality Disorder is ‘Bad’ and this is what Hannah Bonser is now judged to be. She’ll go to prison not hospital.

The jury at Doncaster Crown Court accepted medical evidence suggesting Bonser suffered from a Personality Disorder. Essentially, she knew what she was doing.

The conception from both the public and aggrieved families is often that a ‘proper’ sentence is infinitely more acceptable than the apparently soft option of a psychiatric bed. Part of the argument around this case was that the stabbing of Casey Kearney was a calculated and manipulative act designed to achieve Bonser’s demands for hospital admission. To have received a Mental Health Act section might have been seen as a triumph for Bonser’s manipulation, and one could understand how that might be seen as unacceptable by many.

To Inquire or Not Inquire?
Nonetheless, an inquiry will now take place and the report will tell us something of how a family have lost a 13-year old girl who just happened to be in the wrong place at the wrong time. The court has already delivered it’s verdict on Hannah Bonser, but the inquiry will hopefully reveal a highly complex interaction between a twenty-six year old woman, her troubled background, her environment, her mental state, the services she turned to for help and the killing of Casey Kearney.

There are some who now call for the end of mandatory inquiries into each and every mental health related homicide. I wouldn’t disagree. It’s a hugely expensive procedure which, as we’ve already seen, throws up very similar conclusions time after time without seemingly making much difference.

But perhaps we should continue to study events such as these which, incredibly rare as they are, remain sufficiently horrific to merit the deepest scrutiny and may help us to at least try to prevent the preventable in future.