Homicide thematic review v2 - Flipbook - Page 7
Summary and conclusion
We believe the issue of predictability and preventability
warrants much further discussion.
A very tightly defined legalistic framework does not always
provide the scope for narrative outcomes, nor for the
portrayal of the complexity of need and interventions or
services on offer. Mental health care and human behaviour
is not an exact science (such as physics) and there are no
universal laws that guide behaviour, thus making
predictability and preventability a contested area.
We believe a more narrative approach to the issue of
predictability and preventability can provide a more
balanced opportunity for learning and for the resolution of
the understandable pain and distress that the majority of
people experience after a homicide incident.
Other key points for conclusion include:
•
There are consistent recommendations relating to often
limited and incomplete investigation processes,
management of and quality assurance of the
investigation and report.
•
Real assurance of implementation of internal
investigation recommendations is often lacking. The
solution to this lies in a more robust investigation
process, with SMART and sustainable
recommendations with a focus on outcomes, not just
process changes.
•
Training is an issue, not just on specific subjects but
also to the quality and timeliness of investigations. There
is a common theme about the inadequate quality of
many of the SI investigations and reports. This is
reflected in the recommendations for training around the
SI process.
•
The lack of family inclusion in serious incident
investigations is a common finding.
•
One final area which causes us concern is the nature
and standard of risk assessments. Many service users
will be at low risk whilst in in-patient care, as admission
is the mitigation for the risk.
What is most important is the consideration of the risk
posed by the individual, in the community without the
protective factors of admission. Far too often teams forget
or underplay the importance and security that inpatient
settings have on the persons vulnerability to their exposure
to their ‘day-to-day life’.
The protective factors which inpatient care offers seems to
have been missed or misunderstood. This was a point
made in Savage v South Essex Partnership NHS
Foundation Trust, which found that the context of future risk
was the most important consideration, not just the risks
posed by that individual at that time in that setting.
From the cases used for this thematic review 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 are major
concerns. This background further increases the risk of
communication breakdown and understanding. It is
therefore extremely important that channels of
communication, professional escalation and sharing of risk
are fundamental parts of the jigsaw that builds the whole
picture of the individual.
As we go forward with new mental health service structures
and the challenge of limited resources and increased
demand it is important that team and organisational
memory becomes the glue that holds the service users care
together. With the extra demands of staff shortages, locum
and agency staff, we must ensure that knowledge and
understanding of service users at risk is retained and their
risks managed within teams, and that individuals, teams
and organisations do not forget the important lessons that
this review has highlighted.
Questions for individuals, teams and senior leaders:
Individual practitioner level:
• Do I understand my organisations policy on risk? Am I up to date with my training? Am I making full use of positive
safety planning in my coproduced care plans? Am I making full use of my clinical supervision?
Team level
• Do we do all we can to support each other with complex cases and formulating care plans?
• Are we practising compassionately with one another, helping and supporting and recognising the emotional energy in
the team – especially when work rate is high meaning potential for burnout is increased?
Board level
• Are we looking in detail at themed reviews of our serious incidents?
• Do we know our ‘hot spots’ and areas most under pressure – and are we providing adequate support?
• Are we setting the right recovery focussed culture for positive risk taking – how do we know? Can we truly evidence
‘lessons have been learned’ or is this just another soundbite?
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