Why Does it Keep Happening

Mny studies show mentally ill people who kill were not getting the care and treatment they needed.

  • Many Mental Health Services are in denial about violence
  • They are failing to investigate properly
  • They are failing to learn lessons
  • They have a culture of secrecy
  • They treat symptoms not causes
  • Psychotic patients often don’t think they’re ill

Mental health services are in denial about violence

For many mental health practitioners and campaigners violence is a taboo subject. Some deny it even exists. They do so out of an understandable but misguided fear of ‘stigmatising’ the mentally ill. Actual levels of violence are minimised or explained away – which leaves services unprepared and surprised when violence does actually occur. This denial also means health authorities are often reluctant to investigate homicides as fully and as quickly as they should.[1]

Mental health services are failing to investigate properly

A review of many mental health homicide investigations reveals many mental health trusts are failing to investigate such cases properly. Some refuse to commission independent inquiries despite a clear requirement by the Department of Health to do so. Some rely instead on the internal reports of the mental health trusts who are effectively investigating themselves. If they do commission inquiries, there is often no member of the panel that doesn’t have a connection to mental health services in some form. They are invariably delayed in starting, fail to engage the victims’ families as they should, and are shrouded in such secrecy as to prevent effective public scrutiny. There is currently no effective oversight to make sure Strategic Health Authorities and Mental Health Trusts are carrying out their obligations as they should.[2]

Mental health services are not learning lessons

Analyses of many mental health homicide inquiries since 1993 show the same problems keep occurring. Typically these include a failure to keep proper records; failure to plan care properly; failure to do adequate risk assessments; failure to treat drug problems; failure to listen to families & carers; failure to follow up missed appointments; failure to ensure medication is taken; and a failure to assertively treat deteriorating patients. These same problems crop up again and again in independent investigations. They have also become the subject of official national and professional guidance. Recommendations for change appear to be routinely ignored without sanction. Despite all the action plans and new policy initiatives there is little evidence that lessons are being effectively learned because the number of mental health homicides continues to rise.[3]

Mental health services have a culture of secrecy

Many mental health professionals appear reluctant to share patient information with other agencies out of a misplaced fear of breaching ‘patient confidentiality’. This overriding concern for the rights of the patient over public safety can have terrible consequences. Patient confidentiality has now become so pervasive that independent inquiries even have to request consent from the killer before they can start to investigate the case.[4]

Treating symptoms not causes

Many seriously ill psychotic patients are admitted to hospital when they are in crisis, only to be released days or weeks later when medication has stabilised their condition. Little attention is given to their long term problems – most commonly treating their drug abuse effectively. It makes little sense for a drug abusing psychotic patient to have a series of short term admissions only to be released back to an environment where street drugs are readily available at the first hint of difficulty.[5]

Seriously ill psychotic patients often don’t realise they are ill

Seriously psychotic patients often have little insight into their condition and don’t believe they are ill. They will stop taking their medication and not comply with treatment because they believe they don’t need it. The current culture of ‘service user centrality’ is entirely focussed on the patient deciding when and what treatment they will receive. This is fine for people with insight who want to get better but can be catastrophic for seriously ill people who don’t even realise they are ill.[6]



    Mental Health Campaigners minimising the problem (amongst others) “The degree to which the [danger posed by mental health patients] has been overstated is considerable.” Andy Bell, Mental Health Alliance, Independent – 10 December 2006 “Focusing on homicides is a mistake. They are freak events” Tom Fahy, Professor of forensic mental health, Institute of Psychiatry. Mental Health Today November 2006 page 8 ‘Time to Change’ Summer advertising campaign;
    Paul Farmer, Chief Executive Mind (BBC News 28 July 2009);
    Royal College of Psychiatrists, Changing Minds campaign –
    page taken down after intervention by hundredfamilies.org
    Prof George Szmukler, Institute of Psychiatry.

    The Chief Executive of the NHS had to remind Strategic Health Authorities of their obligations to commission homicide inquiries after it emerged many weren’t bothering
    National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Independent Homicide Investigations. April 2008 found 30% of homicides by the most seriously ill mentally ill people who were under an enhanced programme of care did not receive a full independent investigation as they should have done. (p3)
    In 2008, the Healthcare Commission published ‘Learning from Investigations’. It 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” 

    National Confidential Inquiry into Suicide and Homicide by people with mental Illness. Independent Homicide Investigations. April 2008 http://www.medicine.manchester.ac.uk/psychiatry/research/suicide/prevention/nci/reports/HomicideInvestigationsReportApr2008.pdf
    M McGrath & F 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
    M Howlett, Victims and Survivors in: Mercer et al. Forensic mental health care. A case study approach (2000);
    C Parker & A 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;
    C Kaye and M Howlett. Mental health in the slow lane. Health Service Journal, 5 Nov 2008
    Personal knowledge and communication with the families of Ben Cargill, Tom Easton and Colin Johnson.
    Case of John Bryceland who murdered his partner Jacqueline Hughes, Glasgow Aug 2007.(She pleaded to section him, MH services said they couldn’t discuss it with her, he killed her days later).
    NHS West Midlands: Report of the Independent Inquiry into the care and treatment of Mr Glaister Earle Butler, (2009)

    Glaister Butler report recently unavailable on the above link but is available here 5.2MbKiller’s consent from:
    NHS National Patient Safety Agency. Independent investigation of serious patient safety incidents in mental health services. Good practice guidance. (Feb 2008) p 13 & 35

    Interviews with Consultant Psychiatrists:
    Dr Paul McMullen, Dr Trevor Turner, Dr David James and Dr Tony Maden
  6. I’M NOT ILL
    Avon and Wiltshire Mental Health Partnership NHS Trust. Root Cause Analysis Report. Fatal Stabbing of PH [Philip Hendy] by SN [Stephen Newton] 29 April 2007; Sept 2007 R V Newton Trial transcript – Bristol Crown Court October 2008.
    Report to the North East Strategic Health Authority of the Independent Inquiry into the Health care and Treatment of Garry Taylor, October 2007.
    E Fuller Torrey. The Insanity Offence. New York & London 2008,
    Chapter 7 – ‘God does not take medication’ p 111
    NHS London/Caring Solutions Report ‘Learning from Experience’
    April 2008, p 56 (LINK)

3 Replies to “Why Does it Keep Happening”

  1. Dear Julian
    All of your reasons are clearly evidenced, but I think that there is another conceptual reason why it keeps happening.
    There are two ways of treating the mentally disordered after the acute crisis has been assessed and managed. You either keep them well, or you treat them when they become ill (responding to relapse for example). Both models of care exist in current practice, but they are not self aware and not always deliberately deployed (or explicitly chosen) as risk management strategies.
    The civil rights of all citizens tend toward the treating us only when we become ill – and this works perfectly well for the vast majority of people – and it is entirely consistent with the Law in particular Mental Health Law, and the Human Rights Act – it also suits restricted or at least limited budgets. If I had a single episode of depression 10 years ago, I would take a dim view of a mental health service checking in with me on a monthly basis to see if I was still well, indeed that would probably be a contravention of my Article 8 rights, and I would protest that they must surely have something more pressing to spend their money on.
    However, there are a critical few for whom this is the only sensible approach. Put simply if I am of a nature to be mortally dangerous to others when I become ill, then you had better keep me well, and to not do so threatens the rights and the safety of the general population. Re-reading the inquiries with this lens sheds a new light on the orientation of services that might in fact have acted differently if they had set out to ensure that the patient remained unsupervised for any length of time only if they could satisfy themselves that they remained well, rather than they were not satisfied that they were unwell.
    The problem is that 1)we are not clear about this dynamic, and services are not always self aware of where they stand on this 2) we have not developed a robust enough way to identify these critical few cases before they cause irreparable damage and sadly 3) we do not explicitly set out to keep those individuals well in the long term often enough once they have made their risks explicit.
    For example, a case might be managed by specialist services under the “keep them well” model for some time and consider it appropriate to transfer the case to community services after a significant period of stability, without fully appreciating that the community services will be operating under a monitor for signs of illness approach, which sadly in many cases that have led to inquiries turned out to be too late. Neither service might be aware of the conceptual schism that existed between their approaches, so it would not be taken into account in handing over the care.
    I sincerely believe that the lack of debate and understanding of this deceptively simple dynamic is at the root of the multiple and repetitive homicide inquiries – in particular cases where the perpetrator has shown grave risk in the past. My own experience as a Forensic Psychiatric Social Worker was that I was working solely in the keep them well model without realising that my care plans, and relapse prevention strategies were being interpreted by community services from the perspective of managing my patients when they became sick. We used the same law, and the same language but sadly the differences in our approach did not become apparent until there was another significant victim and two families (or more) had been for ever altered.
    Part III of the mental health act allows for the recall of persons before the suspicion of relapse has “ripend” into a demonstrable relapse and in my opinion it is also possible in cases where a clear pattern has been observed to detain persons under Part II (civil sections) on the basis of the nature of their illness at a stage before known risks to themselves or others have actually been enacted. Sadly, unless the clinicians have clearly posted their colours to a treatment plan that intends to keep the patient well, (and reacts to the possibility that their presentation has changed for reasons unknown) rather than to respond to them once there is clear evidence of relapse, we will continue to read, with regret that although the care team responded, it was too little too late.
    Unless or until we properly describe and explore this dynamic we will be unable to properly answer the reasonable question of why did this that or the other tragic event happen, and perhaps just as importantly we will not develop the services necessary to identify these critical few, and keep them well, in all of our best interests including the patients themselves.

  2. I personally feel that this will continue being a tough problem to control
    simply cause it is not always easy to pick out mentally ill people who pose a threat to people of sound mind.

  3. Good website but the biggest misconception is that there is any way to accurately predict homicide and suicide (there isn’t). “Little attention is given to their long term problems – most commonly treating their drug abuse effectively” – this assumes there are effective treatments for drug problems (there aren’t) “failure to follow up missed appointments” – this assumes patients would be happy to engage when usually they are not (paranoid does not mean detainable), plus as there is usually insufficient evidence to support detention, they are entitled to not engage and staff are not entitled to harass “failure to ensure medication is taken” – patients are always encouraged to take medication, but if not detainable, its is their right to refuse “failure to assertively treat deteriorating patients” – the MHA is designed to be difficult for doctors to apply (this is considered a “plus” by many) and obvious resource limitations (why should the NHS resource a service that doesn’t deal with “illness” such as cancer and instead only deals with “mental issues”) etc? I think there is a failure of honesty, to directly state the limitations of the effectiveness of all treatments (not just medications), and the impracticality of safely looking after a very ill patients in the community, when ideologically that is where society wants such people to remain. Ultimately these are all signs of a plague of chickens that have come home to roost.

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