Themes arising from recent mental health-related homicide investigations

1. Themes arising from recent
mental health related
homicide investigations
March 2018
All rights reserved. Niche Health and Social Care Consulting

2. This review
• Niche Health and Social Care Consulting provide independent
homicide investigations on behalf of NHS England (under the NHS
Serious Incident Framework SiF, 2015).
• We have worked on multiple investigations and serious case reviews
and have amassed a significant bank of primary research and
unique insights.
• This thematic review aims to provide our clients, commissioners and
regulators with a useful analysis of the prevalent themes and key
areas for learning from twenty three investigations undertaken
between June 2010 and December 2016

3. Specific review areas
1.Terms of Reference – how these are devised.
2.Recommendations – areas arising the most frequently.
3.Contributory factors – the most frequently emerging.
4.Notable practice – sharing things that work well
5.Predictability and preventability – assessing outcomes

4. Terms of reference
Distinct areas which commonly arise in the terms of reference for all
cases. These include:
• Review the adequacy of risk assessments and risk management,
including specifically the risk of harming himself or others;
• Reviewing the care, treatment and services provided by all
stakeholders, including the local authority and other relevant
agencies from first contact with services to the time of the incident;
• Reviewing the appropriateness of the treatment of the patient(s)
involved in the light of any identified health and social care needs;
• Examining the effectiveness of the personal plan of care including
the involvement of the individual and their family

5. Terms of reference
• Reviewing and assessing compliance with local policies, national guidance
and relevant statutory obligations;
• Identifying both areas of good practice and areas of concern;
• Considering if the incident was either predictable or preventable;
• Reviewing the Trust’s internal investigation and assessing the adequacy of
its findings, their own recommendations and action plan;
• Reviewing the progress that the Trust has made in implementing their
action plan (usually in 6-12 months);
• Involving the families of both the victim and the perpetrator as fully as is
considered appropriate, in liaison with Victim Support, police and other
support organisations; and
• Providing a written report to the Trust that includes measurable and
sustainable recommendations.

6. Terms of reference
Always include a requirement to review the predictability
and preventability of the incident.
But some noticeable changes:
• a move towards more outcome focussed, measurable and
sustainable recommendations. Unless the change can be
sustainable and measurable, we can never truly say that
lessons have been learned.
• More recommendations around broader governance at an
organisation and system level should also be included in terms
of reference as a matter of course.

7. Recommendations
• Total of 161 recommendations, 23 investigations, 19 thematic areas.
• most frequent themes for recommendations are
• the failure to follow policies and practice guidance (or the absence of these),
• organisational failure to audit the implementation of internal recommendations
and provide lasting assurance of change
• lack of, or poor, risk assessments - fundamental to mental health care delivery.
But:
• significant similarities within the recommendations made across 14 organisations.
• This indicates that there is a lack of ‘sharing’ of this key intelligence and learning
between providers locally and nationally, and / or an inability to embed sustained
improvements across the mental health sector

8. Recommendations
0 5 10 15 20 25 30
Application of policy/practice guidance/assurance of…
Clinical Risk Assessments/risk registers
Trust Board Ownership & Scrutiny/organisational learning
information gathering/sharing from external stakeholders
Record Keeping/care planning/Assessments
Communication to and from primary care
Lack of communication with service users/ Families
Lack of staff Training
Lack/reviews of Care Pathway
Lack of CPA / care co-ordination processes
Implementation of Nice Guidance
Medication Management
Miscellaneous
Crisis Management & Escalation
Lack of co-ordinated discharge planning
Internal SIs lacking robust scrutiny
HR Processes not followed
Staff supervision (Clinical & Managerial)
DNA process
26
18
14
14
13
12
11
8
7
7
6
6
5
5
2
2
2
2
1
By theme

9. Recommendations
• The top two recommendations relate to the individual practice
and behaviour of practitioners, or teams.
• Third theme is specifically about the culture, organisational
context and the systems (or lack of) in place to embed learning
and cultural or practice change.

10. Recommendations
Policies/Practice Guidance/Audits and Assurance
Overriding themes:
• staff not following policies, or not being aware that the policy
existed;
• for organisations having systems where assurance can be
obtained that staff are made aware of policies or strategies and
able to follow them; and
• the lack of audits that would enable assurance around the
clinical effectiveness of systems and processes being in place.

11. Recommendations
Clinical Risk Assessments
Risk assessment is the process that helps organisations understand the range of risks
they face, the level of ability to control or mitigate those risks, their likelihood of
occurrence and their potential impact.
Tone and preparedness of the Board to support a non-punitive and positive risk taking
culture will have a direct impact on the collective ability of teams, and individual
practitioners to take positive risks.
Clinical risk assessments not updated or followed, or mitigation not being implemented
was a recurring theme. Other issues within this theme include:
• Poor implementation of systems and processes that provide assurance that risk
policies are followed such as signing sheets for staff;
• Ensuring that processes are in place to provide assurance that documentation is
updated and communicated;
• Uniformity in the implementation of policies;
• Risk Management Policies to correlate risk assessment, care planning and CPA; and
• Risk Register is maintained and updated

12. Recommendations
Trust Board Ownership & Scrutiny /Organisational Learning
Whenever there are serious incidents in healthcare, it is a truism that ‘lessons will be
learned’.
But in very many cases, it is difficult to demonstrate that this is the case.
In many of our investigations we found the initial internal investigation was weak, with
recommendations that needn’t lead to any service change (“the Trust should consider
reviewing…”).
Other issues include:
• Lack of oversight and scrutiny of serious incidents;
• Lack of robust Board Assurance Framework; process capturing team, pathways level
risks where incidents may be on the increase;
• Poor application of CPA and risk management processes in the cases concerned; and
• Lack of evidence that changes have been embedded and the board assured of this.

13. Recommendations
Background issues
• Although Board aware of, and updated of progress on the homicide / serious incident
investigation, mechanics of action planning and the delivery of improvements can often
disappear into the organisational system.
• E.g.- not always acknowledged that where an action exists this implies that there is a
deficit somewhere – and there is not always an automatic translation of this into a risk
register. In several of the investigations reviewed, also a background issue of service
reorganisation, high churn of significant team members and senior leaders, up to the
Board (as well as the Responsible Clinician and Care Coordinators).
• Often noted a frequent high use of locums and agency staff due to staff shortages.
• This can mean loss of organisational memory about a few higher risk individuals who may
temporarily drop from sight.
• Importantly, churn and fragmentation along the care pathway can lead to a lack of
assertive leadership with individuals care and treatment which can have catastrophic
consequences

14. Contributory factors
• According to the NPSA, Contributory Factors affect the performance of
individuals, whose actions may have an effect on the delivery of safe and
effective care to patients
• Hence the likelihood of:
• Care Delivery Problems (CDP) or
• Service Delivery Problems (SDP) occurring.
• A root cause is also a fundamental contributory factor.
• In patient safety terms , a root cause is the earliest point at which action could
have been taken to enhance the support system or prevent the event, or to
mitigate the harm from the event.
• We often see the root cause identified as the patient causing the homicide, or that
they have a mental illness,
• The root cause is the actual system failure which could have prevented the
incident.

15. Contributory factors
Common themes
Team factors:
Role congruence
Leadership
Support + cultural factors
Communication factors:
Verbal
Written
Non-verbal
Management
Organisational + strategic factors:
Organisational structure
Priorities
Externally imported risks
Safety culture
Equipment + resources:
Displays
Integrity
Positioning
Usability
Task factors:
Guidelines/ procedures/protocols
Decision aids
Task design
Individual (staff) factors:
Physical issues
Psychological
Social/domestic
Personality
Cognitive factors
Working condition factors:
Administrative
Design of physical environment
Environment
Staffing
Workload and hours
Time
Patient factors:
Clinical condition
Physical factors
Social factors
Psychological/ mental factors
Interpersonal relationships
Education + Training Factors:
Competence
Supervision
Availability / Accessibility
Appropriateness

16. Contributory factors
16%
14%
12%
10%
10%
9%
8%
6%
5%
5%
3%
3%
1%
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Staff training issues - risk assessments/care…
Lack of information gathering from stakeholders
Failure to obtain information from families
Lack of communication between services
Inconsistent doccumentation/ management of risks
Failure to follow policies/best practice guidance
Poor documentation/record keeping
No psychological assessements/referals
Failure to follow discharge planning/CPA
Mismanagement of medication
No discharge planning
No Forensic assessments/referalls
No dedicated PD Services

17. Contributory factors
Top five contributory factors groups accounted for 61% of all factors.
Key areas:
• risk assessment, gathering information, communication with relatives, documentation;
• lack of staff supervision within teams;
• sharing of information with key stakeholders; and
• obtaining information from families and other services/ agencies.
Other important factors included:
• The forensic and psychological assessments that were recommended in the Mental Health Tribunal
did not occur;
• Profile Assessments did not adequately document or consider historical and current risk factors;
• Despite being in regular contact with the police the ward staff failed to obtain any information on
forensic history;
• Discharged from the inpatient unit without the appropriate Section 117 planning;
• There were no discharge plans in place from the inpatient unit;
• Community services only had minimal information about both risk factors and support needs; and
• Medication was changed at a significant point, when it was unclear if reported symptoms were due to
head injury or mental health.

18. Notable practice
Examples include:
• “Clinical staff reported that they felt well supported after the homicide”.
• “The engagement of and communication with families after the homicide
was sensitively managed and communication remained open through the
independent investigation”.
• “The internal report was well structured and provided a comprehensive
detailed root cause analysis of the care of B”.
• “Regular communication from Hospital to GP”
• “Regular communication from consultant psychiatrist to GP”
• “The Trust’s internal investigation report was shared with the family, and
later adjusted to include family perspectives on the content”

19. Notable practice
• But is this ‘notable practice or just doing what they should have
done anyway?
• We suggest the following as notable good practice:
•Where the person in care and their family was fully involved
in their care planning;
•Where positive risk taking, personal choice and personal
strengths was discussed and formulated according to the
persons needs; and
•Where a recovery focus demonstrated a focus on personal
safety planning and mitigation in place for extra support when
needed.

20. Predictable &
preventable
• This is always a fundamental issue and included within all terms
of reference: was the homicide either predictable or
preventable?
•Predictable is ‘the quality of being regarded as likely to happen,
as behaviour or an event’.
•Preventable means to ‘stop or hinder something from
happening, especially by advance planning or action’ and
implies ‘anticipatory counteraction’; therefore for a homicide to
have been preventable there would have to be the knowledge,
legal means and opportunity to stop the incident from occurring.
• Some new terms of reference also include ‘avoidable’.

21. Predictable &
preventable
• Within these 23 cases, no cases were both predictable and
preventable, two cases were found to be preventable, and in
only one case was it found predictable that the homicide would
occur:
• “We concluded that even based on the partial information that
was known at the time of the incident, it was highly predictable
that Mr C would be involved in another impulsive violent
incident. Such an incident would either involve someone who
was known to him or a stranger, as both had been previous
victims of violent assaults by Mr C.”

22. Predictable &
preventable
• But even here, the predictability is of another violent incident, not the
homicide of that victim.
• By widening the definition of predictability in this way we identified a further
12 cases. These 12 cases, using the ‘not predictable, but.’ approach, all
note the predictability of a future violent attack, just not the death of that
victim on that day.
• Of the two that were preventable, we note that the preventability of the
offence is caveated:
• “Our view is that the homicide of Adam was preventable, taking the longer
term view of B’s journey through mental health services”
• “The violence might have been preventable if the risk assessment and
management plan had been more robust, resulting in better care and
treatment for JK”

23. Predictable &
preventable
• Findings of predictability and preventability often requires walking the tightrope
between the conflicting views of a Trust, and a family.
• Legalistically we are asked to consider the predictability based on “that person on
that day”, and preventability on “would that action have prevented the homicide”.
• Not surprising that homicides are rarely found predictable or preventable with
such a tight definition.
• However, it is clear that in very many cases the likelihood of future violence was
well known, and that there were often deficits in a persons care.
• For bereaved families and the wider public this can appear as if services are
hiding behind a rigid definition.
• It is clear is that strict legal definitions of predictability and preventability are not
satisfying families, and that sticking to a legalistic framework can be unhelpful. A
more narrative based approach is required.

24. Summary &
conclusions
• It is clear that each individual has received a complex package of care
often involving a number of multi-disciplinary professionals and services.
• This increases the risk of potential breakdown in communication between
teams, service user and family.
• The service user is often part of a complex family structure within which
domestic violence and mental health (and often substance misuse) are
major concerns.
• It is therefore extremely important that channels of communication,
professional escalation and sharing of risk are fundamental parts of the
jigsaw.
• Team reorganisation, high use of locums and agency staff must be high
risk factors and barriers to effective use of ‘organisational memory’ for both
individuals care and systemic approaches to managing risk.

25. Any questions?