Summer Newsletter 2017 - Flipbook - Page 7
The Homicide Brief – thematic review
Exploring homicide investigations, Nick Moor
Introduction
Niche specialise in investigations. Just over half of our work
in this area involves investigating the care and treatment of
a person using mental health services involved in a
homicide. Over the last few years we have collected an
extensive bank of primary evidence of shared factors in a
number of such investigations. Our first thematic review in
2015 looked in detail at shared root causes between
investigations. Our most recent review assessed 23
investigation reports in order to provide useful analysis of
the prevalent themes and key areas for learning.
Common themes
During our review we explored the following key themes: investigation terms of reference, recommendations,
contributory factors, good practice and assessments of predictability and preventability. We found several
interesting shared areas which include:
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Forensic and psychological assessments recommended by the Mental Health Tribunal often did not occur
Profile Assessments did not adequately document or consider historical and current risk factors
Failure to obtain information on forensic history for current inpatient spells
Discharge without the appropriate Section 117 or other routine planning
Community services given insufficient information about both risk factors and support needs
Our review also found that communication between teams and with families / carers remained an ongoing issue
as was the important fact of communication between services, particularly involving the transfer of a service user
between services. In addition to this we found that the issue of demarking predictability and preventability
warrants further discussion as applying very tight legalistic definitions does not always reflect the complexity of
the case and this can become a very contested area, especially for families involved.
It is without a doubt that any mental health homicides
causes untold pain and distress to families, staff and
other service users and it is critical to ensure that learning
across the system is sustained and embedded long into
the future.
As we go forward with new mental health service
structures within complex systems, and the challenge of
limited resources and increased demand, it is important
that individuals, teams and organisations adapt their
thinking and share their intelligence.
To read this important report in full please go to
www.nicheconsult.co.uk / library/articles. You can
contact Nick, who is a Partner at Niche via the
following:
Nick.moor@nicheconsult.co.uk
Individual and team challenge questions:
1.Do I understand and apply my organisations
policy on risk?
2. Am I making full use of positive safety planning
in my coproduced care plans, and am I
documenting this?
3. Am I making full use of my clinical supervision?
4.Does our team do all we can to support each
other with complex cases and formulating care
plans?
5. Are we working compassionately with other
services and those outside of our ward
environment?
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