An inquiry into the methodology of mental health homicide inquiries: validity of Root Cause Analysis

Abstract

All managed healthcare systems have processes in place for learning from adverse events. In mental healthcare systems, the most serious adverse events include homicides perpetrated by patients who were in receipt of mental healthcare at the time of the homicide. England has had a well-established system of independent inquiries of these mental health homicides since the 1990s, which have a significant impact on national policy, clinical practice and the public’s perception of safety of mental health services.

Nearly all western healthcare systems mandate to the use of Root Cause Analysis as the methodology to investigate adverse events. Root Cause Analysis originated in the manufacturing industry, and whilst authors have questioned its effectiveness in healthcare, its validity has received less attention. The use of Root Cause Analysis is likely to be particularly problematic in the investigation of mental health homicides, as it encourages an assumption of retrospective linear causation and does not recognise that mental health systems are complex adaptive systems with emergent causality.

This research has examined 162 independent mental health homicide inquiries published in England between 2010 and 2023. It shows that there are significant variations in methodology employed by independent inquiries, with the methodology remaining unclear in a large number of reports. Independent mental health inquiries in England are required to comment on predictability and preventability of the homicide, and my review shows that these are conceptually problematic notions, with no definitions or thresholds specified in national guidance, leading to significant variation in inquiry reports. This research shows that inquiry reports do not acknowledge cognitive biases.

I have also examined the recommendations and action plans of independent inquiry reports, and shown that nearly all recommendations and actions make changes at the micro, or technical level, with little evidence of systemic or sustainable change.

My findings have implications for national policy, in terms of cost and improving safety of mental health services. This research shows that there has been little use of human factors or systems thinking in independent mental health homicide inquiries, despite the increasing recognition of the importance of these in understanding complex adaptive systems. It finds that there are significant gaps in the research regarding the most appropriate methodology for mental health homicide inquiries.

More information

Identifiers

ORCID for David Baldwin: orcid.org/0000-0003-3343-0907

ORCID for Julia Sinclair: orcid.org/0000-0002-1905-2025

Catalogue record

Export record

Altmetrics