Citation

Ng L, Merry S, Paterson R, Merry AF. Psychiatry Psychol. Law. 2020; 27(5): 894-911.

Copyright

(Copyright © 2020, Australian and New Zealand Association of Psychiatry, Psychology, and Law, Publisher Informa - Taylor and Francis Group)

DOI

10.1080/13218719.2020.1751329

PMID

33833616

Abstract

We aimed to identify features of New Zealand government-commissioned inquiries into the provision of mental health services after homicides committed by service users. The analysis of five reports from 1992 to 2016 identified similarities across reports, which included documenting a process; responding to a set terms of reference; detailing a case chronology, risk assessment, team and system issues; making recommendations and giving opportunities to clinicians to respond to adverse comments. Differences included selecting key informants and acknowledging limitations of scope. The inquiries did not specify a means to disseminate findings to stakeholders and follow up recommendations. Unrealised opportunities include attention to relationships between stakeholders and ways to support learning from inquiries. There is no standardised approach to conducting statutory inquiries into mental health services following a homicide. This limits the value of such inquiries for learning and service improvement. We recommend a standardised framework be developed to guide inquiries.

Language: en

Keywords

mental health; protocol; homicide; Healthcare system; inquiry; quality assurance; serious incident