Mental health homicide inquiries in England 2010-2023: review of methodology and findings
Mental health homicide inquiries in England 2010-2023: review of methodology and findings
Background: the methodology and impact of independent inquiries of homicides by people in care of mental health services have been questioned. Aims To analyse characteristics of patients who committed homicide, their victims and inquiries published in England between 2010 and 2023.
Method: documentary and thematic analysis of 162 mental health homicide inquiries. We compared characteristics of perpetrators with those from the National Confidential Inquiry into Suicide and Safety (2018), and characteristics of victims with those in the general population of England and Wales. We examined methodology used by inquiries and thematically analysed root causes, contributory factors, recommendations, action plans, predictability and preventability.
Results: fifty-two per cent of perpetrators had a diagnosis of schizophrenia and 52% had a history of non-adherence to medication and follow-up; 71% of victims in mental health homicides were family, friends or partners compared with 44% in the general population; 77% of inquiries used no clear methodology. The most frequent root causes and contributory factors related to deficits in assessment, treatment, follow-up or discharge, and risk assessment. There was no direct link between putative causes and resulting recommendations. The most frequent recommendations related to changing policy, improving clinical governance and training. Only 4% of inquiries deemed the homcide to be predictable and preventable.
Conclusions: there is considerable variation in the methodology of mental health homicide inquiries, with little use of human factors and systems theory. Inquiries repeatedly identify the same themes, and most mental health homicides are found to be neither predictable nor preventable. We make recommendations for improving consistency and usefulness.
Homicide, inquiry, mental health services, predictability, preventability
Deshpande, Mayura
9834def5-9c5c-490d-8714-f86a5b0f64fc
Sinclair, Julia M.A.
be3e54d5-c6da-4950-b0ba-3cb8cdcab13c
Tebbs, Zoe
48b60499-f2fd-4686-a5bf-13b4d038c2ae
Baldwin, David S.
1beaa192-0ef1-4914-897a-3a49fc2ed15e
4 April 2025
Deshpande, Mayura
9834def5-9c5c-490d-8714-f86a5b0f64fc
Sinclair, Julia M.A.
be3e54d5-c6da-4950-b0ba-3cb8cdcab13c
Tebbs, Zoe
48b60499-f2fd-4686-a5bf-13b4d038c2ae
Baldwin, David S.
1beaa192-0ef1-4914-897a-3a49fc2ed15e
Deshpande, Mayura, Sinclair, Julia M.A., Tebbs, Zoe and Baldwin, David S.
(2025)
Mental health homicide inquiries in England 2010-2023: review of methodology and findings.
British Journal of Psychiatry.
(doi:10.1192/bjp.2025.65).
Abstract
Background: the methodology and impact of independent inquiries of homicides by people in care of mental health services have been questioned. Aims To analyse characteristics of patients who committed homicide, their victims and inquiries published in England between 2010 and 2023.
Method: documentary and thematic analysis of 162 mental health homicide inquiries. We compared characteristics of perpetrators with those from the National Confidential Inquiry into Suicide and Safety (2018), and characteristics of victims with those in the general population of England and Wales. We examined methodology used by inquiries and thematically analysed root causes, contributory factors, recommendations, action plans, predictability and preventability.
Results: fifty-two per cent of perpetrators had a diagnosis of schizophrenia and 52% had a history of non-adherence to medication and follow-up; 71% of victims in mental health homicides were family, friends or partners compared with 44% in the general population; 77% of inquiries used no clear methodology. The most frequent root causes and contributory factors related to deficits in assessment, treatment, follow-up or discharge, and risk assessment. There was no direct link between putative causes and resulting recommendations. The most frequent recommendations related to changing policy, improving clinical governance and training. Only 4% of inquiries deemed the homcide to be predictable and preventable.
Conclusions: there is considerable variation in the methodology of mental health homicide inquiries, with little use of human factors and systems theory. Inquiries repeatedly identify the same themes, and most mental health homicides are found to be neither predictable nor preventable. We make recommendations for improving consistency and usefulness.
Text
31st Jan 2025 Homicides paper amended manuscript CLEAN VERSION
- Accepted Manuscript
More information
e-pub ahead of print date: 4 April 2025
Published date: 4 April 2025
Additional Information:
Publisher Copyright:
© The Author(s), 2025. Published by Cambridge University Press on behalf of Royal College of Psychiatrists.
Keywords:
Homicide, inquiry, mental health services, predictability, preventability
Identifiers
Local EPrints ID: 503273
URI: http://eprints.soton.ac.uk/id/eprint/503273
ISSN: 0007-1250
PURE UUID: 7b5e7d89-57d1-42aa-9e53-61b29914a024
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Date deposited: 28 Jul 2025 16:33
Last modified: 29 Jul 2025 01:36
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Author:
Mayura Deshpande
Author:
Zoe Tebbs
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