Abstract
Acts of major violence by people with major mental illness are rare but troubling events. They cause major suffering to the person, their victims, family members of both (who are often one and the same), those clinicians working with the person and the public at large. Subsequent sensationalist reporting in the media can contribute to public fear of people with mental illness. This may contribute to a loss of public confidence in mental health services.
Society's concern about homicides perpetrated by the mentally ill may not be surprising. Tidmarsh [1] noted that societal attitudes to violence by mentally ill persons are influenced by, among other factors, a perceived involuntary exposure to risks related to mental illness, a lack of personal experience of mental illness, and infrequent but catastrophic incidents associated with individuals with mental illness. He notes that adverse incidents in relation to the mentally ill can be more easily attributed to failure on the part of the mental health worker than clinicians in other disciplines.
Public concern frequently demands inquiry into the accountability of mental health services and practitioners. Such inquiries are not new [2–4]. In England and Wales, inquiries into homicide involving mentally ill people have been mandatory since 1992 [5]. Such inquiries are constituted as a panel with a suggested process and format to follow [5]. Their overall aim is to detect system or local errors of practice, and to meet needs of public accountability. Some authors have been critical of mandatory inquiries. Clinicians involved in the care of the individual might be exposed to a lower threshold of professional culpability than the accepted professional standard [2, 3]. They were at risk of being blamed, without consideration of resource and service organization in which they operated [3, 6, 7]. Inquiry results were not collated centrally. There was no evidence that the inquiry panels revisited services to check whether their recommendations had been implemented [3]. There was no consensus on whether or not hearings should occur privately or in public and whether or not consent is needed to be obtained to review the patient records [4, 5]. Inquiries were expensive, time consuming and labour intensive. The application of ‘hindsight bias’ to an event distorts the ‘truth’, and is thus potentially misleading, resulting in a potentially unjust finding [4, 5].
Some authors suggest that mandatory homicide inquiries should cease [4, 5]. These authors suggest that only cases where the perpetrator was in recent contact with mental health services should be included. In addition, others viewed the inquiry process as fundamentally flawed and believed that it should be replaced with more effective internal systems of monitoring and audit [4–6]. Others viewed hazardous events such as homicides by people with mental illness as equally requiring inquiry as mortality reviews in other specialty areas such as obstetrics, surgery and anaesthetics [6].
A different approach, the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness was established in 1991 under the aegis of the Royal College of Psychiatrists to review suicides and homicides by people in contact with mental health services [6]. Since 1996, it has sought to establish two broad aims in relation to homicide [8]. First, to establish the frequency and contributory role of mental illness in a complete national sample of homicides; and second, to examine aggregate data on those in contact with mental health services who commit homicide to inform clinical practice and policy. A centralized data collection system that used information from the Home Office, psychiatric reports for the courts and mental health teams was established [8]. It was hoped that these changes would mean inquiries would improve services rather than blame individual clinicians [5, 9].
The National Confidential Inquiry has recently completed a full report. This report supports the previously known epidemiology of homicide [6]. Fourteen per cent of homicide perpetrators had a mental illness at the time of their offence, and were more likely than non-mentally ill offenders to involve family members as victims. Eight per cent of all people committing homicides had had contact with mental health services in the year prior. Of these, 71% had lost contact with mental health services. The majority had personality disorder or substanceabuse disorder. Twenty-three per cent of those with a mental illness were non-compliant with medication. The report made 31 recommendations including training on risk assessment for all mental health workers, simplification of the administration component of mental health care, changes in the structure of inpatient wards, assertive community outreach and integration of drug and alcohol services [6].
Such data is in some contrast to the results of Wallace et al. [10]. In a case linkage study, records of all persons convicted in the higher courts of Victoria, Australia were searched to see if the offenders also had contact with mental health services prior to the offence. Approximately 25% did, mostly those with personality disorder or substance misuse although those with schizophrenia were also overrepresented.
The New Zealand context
Homicide accounts for 3% of all injury deaths in New Zealand, with a rate for the 10-year period 1978–1987 of 1.6 per 100 000 persons per year and noted by the early 1990s to a rate as high as 3.1 [11]. In Australia, the rate of homicide has been stable for the decade 1985–1995: between 1.8 and 2.3 per 100 000 per annum [12].
In New Zealand, homicides or suicides by mentally ill people have resulted in a series of high-profile inquiries. The deaths of Michael Watene at Oakley Hospital in Auckland [13] and Ian Donaldson [14] contributed to a climate of concern about the status of mental health services to potentially dangerous mentally ill patients in the mid-1980s. This reached a peak in 1987 when a former inpatient of a secure hospital, John Papalli'i, killed two people after having been refused voluntary admission to psychiatric hospital. This particular incident resulted in the Mason Report of 1988 [15], which also inquired into the suicides of 12 mentally ill prisoners in Auckland prisons over the preceding 3 years. The recommendations of this inquiry included a recommendation for the establishment of regional forensic psychiatry services with the aim of providing care to mentally ill offenders.
Despite the establishment of such services, violent incidents by mentally ill persons have continued. Such incidents are often associated with sensationalist media reporting [16, 17]. These events contributed to a further Mason Inquiry in 1996 which found, inter alia, poor funding and organization of mental health services and problems with the introduction of new mental health and privacy legislation in a sector already underresourced and undergoing major structural change [18].
There is no legal requirement for mandatory review following serious events. Deaths will inevitably result in a Coronial Inquest. However, the power to commission inquiries exists in other legislation (for example, Section 95 of the Mental Health [Compulsory Assessment and Treatment] Act, 1992; Section 47 of the Health and Disability Services Act). The Health and Disability Commissioner may also initiate inquiries pursuant to the Health and Disability Commissioner Act. Prior to 1998, decisions to commission such an inquiry were somewhat arbitrary. Factors which were likely to influence this decision were local initiative, particular controversy (be that political, victim or family members concern) and public expectation. More recently, there has been a policy agreement among mental health directors and managers that an inquiry, performed at least by an external psychiatrist or district inspector, will occur into all homicides perpetrated by mentally ill patients. The results of most inquiries are analysed by the Ministry of Health. The results are sometimes made public.
This study seeks to review all such inquiries held by the Ministry of Health for the period 1988–1998 to address questions of the frequency with which such inquiries were held, describe their methodology and seek to determine if there are common concerns emerging from their findings.
Method
All inquiries into homicides, serious violence or offending by psychiatric patients reported between 1988 and 1998 and held by the Ministry of Health were included. This totalled 13 inquiries. All inquiries were read by AIFS, summarized and discussed by the three authors. Emergent trends were noted and recorded. Because 11 were at least partially confidential, only grouped data are presented and no individuals named. Inquiry method, characteristics of the perpetrator, offence, care received and inquiry report and outcomes were summarized. Details of individual cases are not described and methodological factors are emphasized.
The judgement of the inquirer as to the predictability and preventability of the event was sought. Predictability was defined as statements being present which noted that the clinical team could have or should have known that the person was at high risk of committing the act they went on to perpetrate. Preventability was determined by two means. Either that the clinical team could have reduced the known risk, or that even if the high level of risk could not have been known, that risk of violent action by the perpetrator was highly likely to be reduced had the clinical care been of an acceptable standard.
Results
Incidents
Thirteen inquiries into 11 incidents were studied. In two an internal inquiry was held prior to an external inquiry. The internal inquiries were conducted by a manager in one case and a psychiatrist in the other. In both cases, the external inquiry was more comprehensive and critical of the service delivered. The services that commissioned the second external inquiries accepted the more critical external inquiry results. Therefore only the external inquiries in relation to these incidents are included in further analysis.
The 11 incidents resulting in inquiries were of the following types: six incidents of homicide, of which two were of multiple victims and one of murder-suicide; two of rape, two of armed incidents of known patients who were shot by the police and one of the release of a dangerous patient with subsequent threats and arson. All perpetrators were male. Six were of pakeha ethnicity, four Maori and one Pacific Islander. Their mean age at the time of the index incident was 33.6 years. The primary diagnosis was schizophrenia in six, bipolar affective disorder in two, and major depressive disorder, substance dependence and personality disorder in one case each. Six patients had a secondary diagnosis of substance dependence, two of antisocial personality disorder, two of personality disorder not otherwise specified (NOS), and one of an anxiety disorder NOS.
At the time of the incidents, all were in contact with mental health services. Nine cases were in receipt of outpatient care. Of these cases, one was receiving compulsory care, one was in default of inpatient care, and one an inpatient on leave. In terms of legal status, eight were informal, one was a special patient found not guilty by reason of insanity, one was subject to an inpatient Compulsory Treatment Order on leave and one a Compulsory Community Treatment Order.
Three incidents resulted in the deaths of the perpetrators at the time of the event, one by suicide and two as a result of police actions. Following the subsequent legal proceedings where the perpetrators survived, four patients were found not guilty by reason of insanity and three were convicted and made subject to orders of imprisonment. One returned to hospital as a Compulsory Treatment Order patient but was later made subject to a restricted patient order.
Inquiries
The inquirer was a psychiatrist in six cases (four were external and two internal to the service in which the incident occurred), a district inspector (independent legal officer) in one case, a combination of district inspector and external psychiatrist in two cases and a Family Court Judge inquired into two cases. Six inquiries were requested by the service as non-statutory clinical reviews, two were Ministerial Inquiries, one pursuant to Section 47 of the Health and Disability Services Act 1993 and the second pursuant to Section 13 of the Hospitals Act 1957, and three were District Inspector-led inquiries pursuant to Section 95 of the Mental Health (Compulsory Assessment and Treatment) Act 1992.
Three inquiries were held in public and the remainder were restricted. One Ministerial Inquiry had terms of reference beyond the incident in question and is thus atypical of the remaining reports.
The other 10 reports required inquiry into the circumstances of the care delivered to a particular patient alone. The establishment of the inquiries varied from a letter asking for review of the case, to formally established legal proceedings with legal representation of parties. The reports varied in length from four pages (prepared by an external psychiatrist) to 194 pages (prepared by a district inspector and psychiatrist). Those of Ministerial origin were of greatest length and with lengthy recommendations.
All inquiries made findings that were to some degree critical of service provision. The aspects of service provision that were criticized were as follows: mental health legislation (two inquiries), resource size and availability (three inquiries), interservice coordination (three inquiries), policy or procedure of a service (eight inquiries), staff incompetence or negligence (two inquiries) and staff training deficiency (nine inquiries).
The most common errors or deficiencies noted were limitations in service policies and training for staff in specific clinical skills such as risk management. In two cases, specific issues regarding the competencies of individual practitioners were raised. In most other reports, the poor quality of service provision was noted to be secondary to inadequate resources (three cases), poor policies and procedures (eight cases) or inadequate training opportunities for staff (nine cases). Legislative deficiencies were noted in the early inquiries. Since 1994, 2 years after the Mental Health (Compulsory Assessment and Treatment) Act came into force, no criticisms were made of legislation.
The findings and recommendations were made public in all but one case. When individual clinicians were named, edited versions of the recommendations only were released. Recommendations encouraged service improvement, increased resources and new training opportunities for staff. Three inquiries noted that improvements had already been taken in service provision as a result of the incident but prior to the findings of the Inquiry being announced.
‘Predictability’ and ‘preventability’ of event
Of the 11 inquiries, the event was seen by the inquirer(s) to be predictable in two (18%) cases. In one of these, the outcome was preventable also, and in the other, the action of a court prevented clinical intervention. Inquirers found eight events (73%) to have been preventable. This was largely through the identification of significant flaws in service delivery, which, if not present, should have significantly reduced the risk of the violent event occurring. Such flaws included both clinical practice errors and resource, training, policy and coordination failures.
Discussion
Drawing firm conclusions from a small number of inquiries of differing methodology is difficult. They are, however, all that are available for New Zealand over a decade and therefore represent the total material available to study. They are best considered in the context of overseas experience addressing similar issues. We found a number of different types of inquiry into the same type of problem. The exact type of inquiry employed may have been be influenced by the seriousness of the incident and the concern expressed about service provision. We can only comment in a limited fashion on the inquiry designs, but do note that when internal inquiries were followed up by external ones the findings were more critical. As noted, the services that sought external review accepted the more comprehensive criticisms of the external over the internal inquiries, and acted upon the recommendations of the external ones. This contributed to the decision by the clinical directors and managers of mental health services to seek external clinical review following any such incident.
This paper cannot examine the necessity for detailed legalistic inquiries, which may well be required if serious systems errors are suspected. Generally, those performed by external clinicians, if well structured and formally requested, appeared to detect significant clinical and system errors. As noted in earlier English and Welsh series, the inquirers in this series did not have any ongoing role in reviewing the implementation of the recommendations. This task was left to the service, Ministry of Health and government purchasing agency to ensure the recommendations were actioned.
The incidents were inquired into with markedly varying degrees of depth and independence. The emergent themes are remarkably similar to those seen in studies in England and Wales. Skill, coordination and resource gaps were consistently of concern. Legislative concerns appeared to be confined to the period following the introduction and bedding in of the new mental health legislation, but have not remained a persistent problem. We believe that the seriousness of these findings supports in a limited way our sense that there is a need for mental health services to carefully review events of serious violence perpetrated by patients in their care. Tidmarsh [1] noted the need for the adoption of a ‘safety culture’ by the management of psychiatric services. Disastrous events can be formulated as resulting from the breakdown of the ‘organization's safety culture and as a result of failing to follow accepted procedures in circumstances where proceduralization is possible’ [1], p.145].
Our data echo the need for better management and resource provision. As in England and Wales, they suggest the need for better inter- and intraprofessional communication, thorough assessment and monitoring of patients, decisive intervention in high-risk situations, knowledge in the process of ‘risk assessment’, accurate and full record keeping, taking family's concerns seriously, and attention to situations of vulnerability. To achieve these ends resources are required. As stated by Peay [7], ‘attaining high standards requires proper funding. To reach these modest goals, time has to be created. Other jobs must be offloaded for the rounded practitioner if he or she is not to be wasted by the demands of doing that job properly’.
The rates of ‘predictability’ and ‘preventability’ are similar to those found by Munro and Rumgay [19] in their review of 40 UK inquiries. They found 27.5% to be ‘predictable’ and 65% ‘preventable’. These definitions are of course problematic. Clinicians are at best able to assign people to categories of risk in the short term. Making absolute predictions is more flawed. However, the operationalizing of the definitions for this study draw on the appropriate assignment of the person to a risk category on the basis of the information available or reasonably available to the clinician, and therefore provides a useful guide to the quality of risk assessment.
One factor that emerges strongly from this process is that the ability of clinicians to ‘predict’ rare events such as homicide was not overemphasized. Clearly this is a most difficult process, and hindsight bias might well mislead the inquirer and unfairly judge the clinician [20]. What the inquiries did find, and were much more critical of, was the failure of provision of adequate services to patients who were at some degree of risk of such behaviour. They commonly found that better provision of care in general was likely to contribute to lower rates of such events.
Eastman [3] and Szmukler [20] have described some of the drawbacks of inquiries, especially contributing to a culture of blame, of proneness to hindsight bias and to involve great cost and trauma to those clinicians involved. Bennett [2] refers to this as the scapegoating of clinicians. How frequent is this in our sample? This is hard to judge. Only two inquiries found significant errors of competence, but more described errors based on poor policy, resource and training support for clinicians resulting in suboptimal performance. It appears that inquirers were sensitive to the multiple factors that can impede clinician performance, rather than to lay all responsibility at the door of the clinicians.
It is not possible to measure benefit derived from these inquiries directly. There was little evidence that the inquirers were involved in an ongoing manner to ensure that the recommendations were actioned. The responsibility to do so rested with others. This feedback loop could be valuably reconsidered to ensure that the overview of the services gained by the inquirer is best applied to bringing about service improvement.
This small sample suggests, but cannot prove, that external psychiatric inquiry, even when commissioned internally, may be a superior methodology than an inquiry by a psychiatrist internal to the service. The inquiries which involved lawyers as inquirer were longer, more formal and must have been much more expensive. It was not clear to us that these inquiries found greater deficiency, but they tended to be of higher profile. We suggest that the circumstances where the greater cost and formality of such an inquiry may be justified include the suspicion of serious systems failure, major issues of competence, or a very polarized environment already existing around a serious incident. In such circumstances, the legal formality may act as the best protector of the interests of all involved, and justify the greater formality and expense so generated.
As we see it, the aim of inquiry must be a component of quality management, to understand and accept that there are times that serious incidents will occur and that the mental health system has sufficient maturity to study such incidents to attempt to understand their origin. Should systemic or individual clinical factors have contributed, steps can be taken to reduce the risk of recurrence. Such a process reassures those affected (patients, victims, families, wider society) that the mental health system is an open, self-critical one which is keen to understand incidents that are of grave concern to others, learn from them and by so doing reduce the risk of future recurrence.
A methodology of mandatory external psychiatric inquiry is, we feel, a reasonable process. It balances the need for independence and maximizing the opportunity to learn from tragedies, without burdening all with an inquiry of the cost, length and formality of the UK mandatory inquiries. At times the formality of statutory inquiries involving legal officials (such as a district inspector) and ordered pursuant to Section 95 of the Mental Health (Compulsory Assessment and Treatment) Act, 1992 will be necessary. The inquirer(s) should monitor the results of their inquiry to ensure the recommendations are implemented.
Footnotes
Acknowledgements
We wish to acknowledge the assistance of Janice Wilson, Nick Judson and Catherine Coates of the Ministry of Health for their support with this work. We also wish to thank those who allowed us to have access to their reports. The views expressed in this paper are our own.