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
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