Homicide thematic review v2 - Flipbook - Page 6
Notable practice (continued)
•
“Continuity of care by care coordinator and consultant
psychiatrist over a number of years”.
•
“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”.
•
“Policy template with clear rules (internally agreed things
that must be done) and Standards (national standards that
must be followed)”.
•
“Risk register that contains all risks to the Trust, including
risks to quality of clinical care, linked to CQC standards,
that is regularly reviewed”.
•
“Learning lessons policy to share and embed learning
following incidents”.
•
“Ongoing development of Bed Management and
Placement Team to provide a central focus for managing
secondary commissioning of care”.
We have reflected that in our team discussions when
undertaking internal quality assurance on the investigations, a
frequent topic of conversation is whether something is notable
practice, or simply just good practice that should have
happened anyway. There is an obvious issue here with
subjectivity and which criteria investigators should use to
guide what they perceive as ’notable practice’. 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.
5. Focus on:- Predictability and preventability
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.
Preventable = 2
“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.”
But even here it could be argued that the predictability is of
another violent incident, not the homicide of that victim. But,
by widening the definition of predictability in this way (to
include the predictability of a future violent incident), we have
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”.
Summary and conclusion
Again, we have found that a further four cases included a
similar approach to preventability in that the findings are
worded ‘not preventable, but’. In these cases, the ‘but’ implies
that better risk assessment / management / communication /
care / etc. might have made a difference. For example:
“Although we have concluded that the incident was not
preventable we do suggest that if Mr C had been resident in a
more supervised environment, such as an intensive
supported housing scheme, he would have been closely
supervised.”
Making 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”? It is perhaps not surprising then that homicides
are rarely found predictable or preventable if we stick to 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, when all common sense
tells you the opposite is true.
What 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.
We have identified the following results:
Predictable = 1
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:
Neither = 20
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