{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T01:11:09Z","timestamp":1782781869742,"version":"3.54.5"},"reference-count":43,"publisher":"Royal College of Psychiatrists","issue":"4","license":[{"start":{"date-parts":[[2025,4,4]],"date-time":"2025-04-04T00:00:00Z","timestamp":1743724800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/www.cambridge.org\/core\/terms"}],"content-domain":{"domain":["cambridge.org"],"crossmark-restriction":true},"short-container-title":["Br J Psychiatry"],"published-print":{"date-parts":[[2025,10]]},"abstract":"<jats:sec id=\"S0007125025000650_as1\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The methodology and impact of independent inquiries of homicides by people in care of mental health services have been questioned.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S0007125025000650_as2\">\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>To analyse characteristics of patients who committed homicide, their victims and inquiries published in England between 2010 and 2023.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S0007125025000650_as3\">\n                    <jats:title>Method<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S0007125025000650_as4\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"S0007125025000650_as5\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>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.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1192\/bjp.2025.65","type":"journal-article","created":{"date-parts":[[2025,4,4]],"date-time":"2025-04-04T05:04:37Z","timestamp":1743743077000},"page":"698-706","update-policy":"https:\/\/doi.org\/10.1017\/policypage","source":"Crossref","is-referenced-by-count":2,"title":["Mental health homicide inquiries in England 2010\u20132023: review of methodology and findings"],"prefix":"10.1192","volume":"227","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5286-4519","authenticated-orcid":false,"given":"Mayura","family":"Deshpande","sequence":"first","affiliation":[{"name":"University of Southampton"},{"name":"Hampshire and Isle of Wight Healthcare NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1905-2025","authenticated-orcid":false,"given":"Julia M. A.","family":"Sinclair","sequence":"additional","affiliation":[{"name":"University of Southampton"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6140-752X","authenticated-orcid":false,"given":"Zoe","family":"Tebbs","sequence":"additional","affiliation":[{"name":"Hampshire and Isle of Wight Healthcare NHS Foundation Trust"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3343-0907","authenticated-orcid":false,"given":"David S.","family":"Baldwin","sequence":"additional","affiliation":[{"name":"University of Southampton"},{"name":"Hampshire and Isle of Wight Healthcare NHS Foundation Trust"},{"name":"University of Cape Town"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"170","published-online":{"date-parts":[[2025,4,4]]},"reference":[{"key":"S0007125025000650_ref4","doi-asserted-by":"publisher","DOI":"10.1192\/pb.24.1.6"},{"key":"S0007125025000650_ref1","unstructured":"1 NHS England. Independent Investigation Reports. NHS England, 2023\u00a0(https:\/\/www.england.nhs.uk\/publications\/reviews-and-reports\/invest-reports\/)."},{"key":"S0007125025000650_ref22","doi-asserted-by":"publisher","DOI":"10.1097\/PTS.0000000000000169"},{"key":"S0007125025000650_ref11","unstructured":"11 National Health Service (NHS) England. An Independent Review of the Independent Investigations for Mental Health Homicides in England (Published and Unpublished) from 2013 to the Present Day. NHS England, 2018 (https:\/\/www.england.nhs.uk\/south-east\/wp-content\/uploads\/sites\/45\/2019\/10\/independent-investigations-for-mental-health-homicides-in-england-report.pdf)."},{"key":"S0007125025000650_ref28","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2015-005074"},{"key":"S0007125025000650_ref19","unstructured":"19 Department of Health. Independent Investigation of Adverse Events in Mental Health Services. Department of Health, 2018 (https:\/\/webarchive.nationalarchives.gov.uk\/ukgwa\/20130107105354\/http:\/www.dh.gov.uk\/prod_consum_dh\/groups\/dh_digitalassets\/@dh\/@en\/documents\/digitalasset\/dh_4113574.pdf)."},{"key":"S0007125025000650_ref10","volume-title":"Annual Report: England, Northern Ireland, Scotland, Wales."},{"key":"S0007125025000650_ref6","first-page":"24","article-title":"Independent investigations after homicide","volume":"Feb","author":"Pearson","year":"2009","journal-title":"Ment Health Today"},{"key":"S0007125025000650_ref31","doi-asserted-by":"publisher","DOI":"10.1177\/13634593221094703"},{"key":"S0007125025000650_ref34","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1097\/PTS.0000000000000885","article-title":"Patient safety strategies in psychiatry and how they construct the notion of preventable harm: a\u00a0scoping review","volume":"18","author":"Svensson","year":"2022","journal-title":"J Patient Saf"},{"key":"S0007125025000650_ref43","first-page":"59","article-title":"Applying reason: the human factors analysis and classification system (HFACS)","volume":"1","author":"Shappell","year":"2001","journal-title":"Human Fact Aerosp Saf"},{"key":"S0007125025000650_ref23","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2004.010454"},{"key":"S0007125025000650_ref33","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1177\/2516043521992908","article-title":"Beyond root cause analysis: how variation analysis can provide a deeper understanding of causation in complex adaptive systems","volume":"26","author":"Stretton","year":"2021","journal-title":"J Patient Saf Risk Manage"},{"key":"S0007125025000650_ref13","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.316.7138.1154"},{"key":"S0007125025000650_ref42","volume-title":"College Report CR239 \u2013 Supporting Staff Following a Patient-Perpetrated Homicide (PPH): A Prevention and Postvention Framework","year":"2024"},{"key":"S0007125025000650_ref29","doi-asserted-by":"publisher","DOI":"10.5040\/9781509912162"},{"key":"S0007125025000650_ref26","doi-asserted-by":"publisher","DOI":"10.1093\/intqhc\/mzx181"},{"key":"S0007125025000650_ref24","doi-asserted-by":"crossref","first-page":"901","DOI":"10.1136\/bmjqs-2020-012538","article-title":"SEIPS 101 and seven simple SEIPS tools","volume":"30","author":"Holden","year":"2021","journal-title":"BMJ Qual Saf"},{"key":"S0007125025000650_ref15","unstructured":"15 National Health Service (NHS) England. Serious Incident Framework. NHS England, 2015 (https:\/\/www.england.nhs.uk\/wp-content\/uploads\/2015\/04\/serious-incidnt-framwrk-upd.pdf)."},{"key":"S0007125025000650_ref20","unstructured":"20 Department of Health. Article 2 of the European Convention on Human Rights and the Investigation of Serious Incidents in Mental Health Services. Department of Health, 2015 (https:\/\/assets.publishing.service.gov.uk\/media\/5a7f1c04ed915d74e33f4637\/Article_2_advice_acc.pdf)."},{"key":"S0007125025000650_ref5","doi-asserted-by":"publisher","DOI":"10.1080\/14789940410001714857"},{"key":"S0007125025000650_ref3","doi-asserted-by":"publisher","DOI":"10.1080\/09540269775367"},{"key":"S0007125025000650_ref30","volume-title":"NCISH Methodology","year":"2023"},{"key":"S0007125025000650_ref27","first-page":"35","article-title":"There\u2019s a SMART way to write management\u2019s goals and objectives","volume":"70","author":"Doran","year":"1981","journal-title":"J Manage Rev"},{"key":"S0007125025000650_ref35","doi-asserted-by":"publisher","DOI":"10.1177\/2516043519855264"},{"key":"S0007125025000650_ref37","doi-asserted-by":"publisher","DOI":"10.1080\/00207594.2010.501337"},{"key":"S0007125025000650_ref2","doi-asserted-by":"crossref","first-page":"1069","DOI":"10.1136\/bmj.313.7064.1069","article-title":"Inquiry into homicides by psychiatric patients: systematic audit should replace mandatory inquiries","volume":"313","author":"Eastman","year":"1996","journal-title":"BMJ"},{"key":"S0007125025000650_ref21","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1136\/bmjqs-2016-005849","article-title":"The problem with \u20185 whys\u2019","volume":"26","author":"Card","year":"2017","journal-title":"BMJ Qual Safety"},{"key":"S0007125025000650_ref8","doi-asserted-by":"publisher","DOI":"10.1192\/bjp.2023.2"},{"key":"S0007125025000650_ref36","first-page":"34","article-title":"People or systems? To blame is human. The fix is to engineer","volume":"54","author":"Holden","year":"2009","journal-title":"Prof Saf"},{"key":"S0007125025000650_ref32","volume-title":"From Safety-I to Safety-II: A White Paper","author":"Hollnagel","year":"2015"},{"key":"S0007125025000650_ref14","doi-asserted-by":"publisher","DOI":"10.1111\/1468-0009.12166"},{"key":"S0007125025000650_ref38","doi-asserted-by":"crossref","DOI":"10.1017\/CBO9781316415771","volume-title":"The Burden of Proof: Discriminatory Power, Weight of Evidence and Tenacity of Belief","author":"Nance","year":"2016"},{"key":"S0007125025000650_ref25","unstructured":"25 Institute for Health Improvement. Patient Safety Essentials Toolkit: Action Hierarchy. Institute for Health Improvemnt, 2019\u00a0(https:\/\/www.ihi.org\/sites\/default\/files\/SafetyToolkit_ActionHierarchy.pdf)."},{"key":"S0007125025000650_ref40","doi-asserted-by":"publisher","DOI":"10.1192\/bjb.2020.96"},{"key":"S0007125025000650_ref17","unstructured":"17 UK Government. Mental Health Act 1983. UK Government, 1983 (https:\/\/www.legislation.gov.uk\/ukpga\/1983\/20\/contents)."},{"key":"S0007125025000650_ref16","volume-title":"Homicide in England and Wales: Year Ending March 2023","year":"2021"},{"key":"S0007125025000650_ref12","doi-asserted-by":"publisher","DOI":"10.1093\/heapol\/czaa064"},{"key":"S0007125025000650_ref18","volume-title":"Health Service Guidance","year":"1994"},{"key":"S0007125025000650_ref39","doi-asserted-by":"publisher","DOI":"10.1192\/bjo.2020.84"},{"key":"S0007125025000650_ref7","doi-asserted-by":"publisher","DOI":"10.1080\/13218719.2020.1751329"},{"key":"S0007125025000650_ref9","doi-asserted-by":"publisher","DOI":"10.1080\/14789949.2011.617832"},{"key":"S0007125025000650_ref41","doi-asserted-by":"publisher","DOI":"10.1080\/14999013.2015.1075627"}],"container-title":["The British Journal of Psychiatry"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.cambridge.org\/core\/services\/aop-cambridge-core\/content\/view\/S0007125025000650","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T01:04:59Z","timestamp":1768352699000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.cambridge.org\/core\/product\/identifier\/S0007125025000650\/type\/journal_article"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,4]]},"references-count":43,"journal-issue":{"issue":"4","published-print":{"date-parts":[[2025,10]]}},"alternative-id":["S0007125025000650"],"URL":"https:\/\/doi.org\/10.1192\/bjp.2025.65","relation":{},"ISSN":["0007-1250","1472-1465"],"issn-type":[{"value":"0007-1250","type":"print"},{"value":"1472-1465","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,4,4]]},"assertion":[{"value":"\u00a9 The Author(s), 2025. Published by Cambridge University Press on behalf of Royal College of Psychiatrists","name":"copyright","label":"Copyright","group":{"name":"copyright_and_licensing","label":"Copyright and Licensing"}}]}}