Homicide thematic review v2 - Flipbook - Page 2
Introduction
Niche Health and Social Care Consulting are one of the primary providers of 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 Niche homicide investigations both in terms of the investigation process itself and also the
key findings arising from investigation reports. All of the twenty three reports we have reviewed for this summary were investigations
undertaken between June 2010 and December 2016. The analysis relates specifically to homicides which have been committed by
a person receiving care and treatment from NHS mental health services.
We hope that you will find this analysis useful in prompting debate and providing areas for scrutiny within your own care and
treatment protocols, compliance frameworks and assurance arrangements.
Specific review areas
During this thematic review, we will explore shared elements of
the investigative process as well as key findings that are
prevalent within all of the reports, specifically, we seek to make
an assessment of the following:
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
1. Focus on:- Terms of reference
•
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.
What has been noticeable over the time reflected in these
investigations is that the terms of reference always include a
requirement to review the predictability and preventability of
the incident. We discuss this in more detail later, but we note
a trend towards a more narrative based understanding of
predictability whereby a violent incident was predictable, but
not the homicide on that day to that victim.
•
Review the adequacy of risk assessments and risk
management, including specifically the risk of harming
himself or others;
The other noticeable change is a move towards more
outcome focussed, measurable and sustainable
recommendations; this is a key requirement. 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.
•
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;
2. Focus on:- Recommendations
We compared and contrasted the terms of reference for each of
the reports. Whilst there are clear differences relating to each
intrinsic case profile there are distinct areas which commonly
arise in the terms of reference for all cases. These include:
•
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;
•
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);
A total of 161 recommendations were documented in the
twenty three homicide investigations reviewed and these
recommendations have been grouped into 19 themed areas
as demonstrated in chart 1. Out of the 19 key themes, the
most frequent themes in recommendations are around the
failure to follow policies and practice guidance (or the absence
of these), coupled with an organisational failure to audit the
implementation of internal recommendations and provide
lasting assurance of change. This is closely followed by lack
of, or poor, risk assessments which is fundamental to mental
health care delivery.
Within all of the reports reviewed, across 14 separate
organisations, there are significant similarities within the
recommendations made. This could indicate that there is a
lack of ‘sharing’ of such key intelligence and learning between
providers locally and nationally, and / or an inability to embed
sustained improvements across the mental health sector.
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