Learning Lessons

  • Number of mental health homicides are steadily increasing
  • Health authorities are failing to effectively implement the recommendations of previous inquiries.
  • Little evidence that mental health authorities are truly learning from their mistakes – lessons are not being learned.

There have been several hundred independent homicide inquiries since they became a government requirement in 1994. They have made thousands of recommendations for improvements in services.

The recommendations are supposed to help Mental Health Trusts learn from their mistakes to ensure the likelihood of such killings is as low as it could possibly be.

But the same problems keep appearing over and over again.

Among the most common areas of concern are:

  • Failure to keep decent and accurate records,
  • Failure to do adequate care planning,
  • Failure to do adequate risk assessments,
  • Failure to listen to the family,
  • Failure to treat drug problems,
  • Failure to follow up missed appointments,
  • Failure to ensure patients take their medication.

Despite the same recommendations appearing regularly over the last fifteen years, Mental Health Trusts are not still acting on them. They are failing to learn from their mistakes.

And this is despite any amount of Government and professional guidance saying that they should.

In 2008, the Healthcare Commission found that despite the high number of investigations into mental health services:

‘A common theme in these referrals is a failure by trusts to learn from serious untoward incidents’

It’s difficult to understand after so many repeated warnings why the message is still failing to get through.

In OX & BUCKS two inquiries into two serious MH homicides have been lost.

Some of the possible reasons for this are discussed in Why does it keep happening?

SOURCES Common Themes from National Confidential Inquiry into Suicide and Homicide by people with mental Illness. Independent Homicide Investigations. April 2008

(A similar analysis is due to be published by Healthcare Inspectorate Wales in Spring 2010)

Melissa McGrath and Femi Oyebode. Qualitative Analysis of Recommendations in 79 Inquiries after Homicide Committed by Persons with Mental Illness. Journal of Mental Health Law, December 2002 p262 – 282

Michael Howlett, Victims and Survivors in: Mercer et al. Forensic mental health care. A case study approach (2000);

Camilla Parker & Andrew McCulloch – Key Issues from Homicide Inquiries, MIND, London May 1999

Richard Lingham, Echoing Blunders, Sanetalk, Spring 1997;

David Shepherd, Learning the Lessons, Zito Trust, London 1996;

Even the Department of Health acknowledges the ‘distressing similarity’.

Government Guidance on learning from mistakes:

Department of Health, NHS Constitution. 2009.

An organisation with memory (2000)

Building a safer NHS (2001)

Professional Guidance:
General Medical Council. Good Medical Practice (especially paragraph 14)

Health Commission Report ‘Learning from Investigations’ (2008) p 47

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