Should we be worried about the end of the National Confidential Inquiry into Suicide and Homicide?

Jonathan Zito and Christopher Clunis? Mary Povey and Raymond Sinclair? Lin and Megan Russell and Michael Stone? I wouldn’t be surprised if these names didn’t mean anything to you. Why should they? Well, Jonathan, Mary, Lin and Megan were all victims of homicides committed by patients in the care of NHS mental health services during the 1990s. All were major news stories at the time. And, in the case of Michael Stone, one of the perpetrators, for many years after the murders.

The care, treatment and supervision of the three perpetrators in these cases were the subject of major independent investigations commissioned under the then Health Service Guidance (94) 27 Guidance on the discharge of mentally disordered people and their continuing care in the community. I was mental health lead for West Kent Health Authority (WKHA) in 1996 and in the following years I commissioned a few homicide investigations, including the one required into the care, treatment and supervision of Michael Stone. And Robert Francis QC (as he was then) was appointed by WKHA to chair his first inquiry.

Last year The Guardian reported that NHS England would no longer be funding the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH), previously maintained by the University of Manchester. The NCISH database is a national case series of suicide, homicide and sudden unexplained death (SUD) by mental health patients over 20 years. As the NCISH website says “This large and internationally unique database allows NCISH to examine the antecedents of these incidents and make recommendations for clinical practice and policy that will improve safety in mental health care.”

The reaction to the withdrawal of funding has been mixed. Julian Hendy, the founder of Hundred Families, said “This is a risky and reckless decision. A lot of families will feel that their suffering doesn’t matter because of this decision, because no one is now learning from these failures.” Julian has a point, though I don’t think the end of NCISH spells the end of learning.

NHS England has also made the decision to commission fewer independent investigations. Until recently a court’s conviction of a perpetrator automatically triggered an independent investigation. No longer. Instead, NHS England will decide on a case-by-case basis bearing in mind the incident itself, the findings of the court and, critically, the quality of the internal investigation carried out by the trust(s) responsible for caring for the individual.

What is the background to independent investigations into homicides? Why are they commissioned and what is their purpose?

Let me start with a bit of history.

Changes to mental health services in the 1980s & 1990s

The late 1980s and early 1990s were testing times for mental health services in England. Government policy resulted in the large, isolated mental hospitals closing with their patients often moving back to live in the community from where they had originated. New mental health services based in local communities were springing into life and new ways of delivering care being pioneered. I remember colleagues in my community mental health team leaving to start up a new early intervention service based in offices under a flyover in west London. The sense of excitement at the new venture was palpable. Anything seemed possible.

While I doubt any mental health professional was sorry to see the back of the large institutions, no one doubted the challenge or expense of providing mental health care in a community setting. Certainly, I didn’t as a young charge nurse in acute psychiatry at St Mary’s Hospital in central London in the late 80s.

As these examples illustrate, the challenges of community care soon became apparent. In the space of a few years there were a series of homicides and acts of self-harm that underlined how challenging it was to care for seriously ill patients in a community setting. The risks of community-based mental health care represented a major policy and practical challenge for the government of the day. The incidents below prompted significant media and political comment. The Michael Stone case resulted in parliamentary debate and even new legislation.

Homicides & other incidents in the 1990s

On 17 December 1992 Christopher Clunis stabbed Jonathan Zito while he stood with his brother on the platform of the Piccadilly Line at Finsbury Park station. Christopher didn’t know Jonathan. He was a stranger on the platform at the wrong moment. Christopher Clunis was a paranoid schizophrenic and living alone in a filthy bedsit at the time. He wasn’t taking his prescribed medication although he was under the care of mental health and social services. At his trial he was found guilty of manslaughter due to diminished responsibility. He was detained in Rampton Hospital.

Following Jonathan’s death, Jane – Jonathan’s young widow – founded The Zito Trust. Jane and the trust provided support to the victims of homicide and campaigned to improve the delivery of community care. The trust closed in 2009 as Jane thought the charity had achieved its objectives.

On 31 December 1992, Ben Silcock climbed a 25-foot fence into the lion’s enclosure at London Zoo and was seriously mauled by a lion. The incident happened when visitors were present. The lion only released its hold when a keeper fired a rifle shot into the air. Ben needed eight hours of surgery for his injuries. Later it became known that he had been diagnosed as schizophrenic some eight years previously. He was unemployed and living alone at the time of the incident. His father, Bryan, was a journalist for The Sunday Times.

Raymond Sinclair had been in care of mental health services since April 1994 when he was admitted to hospital for the first time. On 3 November 1994 he stabbed his mother to death in the family home in Kent. Raymond’s ferocious attack left his mother with 15 stab wounds. In November 1995 he was found guilty of manslaughter and detained in Broadmoor Hospital. West Kent Health Authority published the independent inquiry into his care and treatment commissioned under HSG 94 (27) in 1996.

On 9 July 1996 Lin, Megan and Josie Russell were tied up and savagely beaten in a quiet lane in the east Kent village of Chillenden. Lin and Megan were killed but Josie survived.

In 1997 Kent Police arrested and charged Michael Stone with the crime. He was in the care of mental health services at the time of the incident. West Kent Health Authority commissioned an independent inquiry into his care, treatment and supervision chaired by Robert Francis QC.

Stone went to trial in 1998 and was convicted. The Court of Appeal ordered a retrial in 2001 and he was re-convicted. In 2006 the courts decided he should spend at least 25 years in prison before being considered for parole.

Michael Stone continues to maintain his innocence and contest his conviction.

The independent inquiry was published by order of the High Court in 2006 and that, by and large, services had done a reasonable job in caring for Mr Stone.

Given this cluster of high-profile incidents over a few years, it is little wonder that by 1994 health ministers had decided that such events warranted independent investigation. Health Service Guidance 94 (27) became policy. It is by this means that independent investigations into homicides came into being. Their purpose was to:

• establish the facts
• appraise the care and treatment provided by the NHS and other agencies to the individual
• provide an account to the family & carers and
• ensure that lessons were identified.

Crucially, each investigation was to be carried out by individuals independent of the provider(s) of care to the perpetrator.

What have these investigations revealed?

There have been many hundreds of independent homicide investigations since the guidance was published in 1994. Verita alone has carried out close to 100. These investigations have revealed a set of themes common to the care and treatment of many perpetrators. For example, they include: unclear diagnosis of the presenting illness; risk assessment with no subsequent plan; poor inter-agency communication; failure to respond adequately to missed appointments; non-compliance with medication; breakdowns in care at the point of transfer between services. There are many more and a homicide investigation today is quite likely to reveal the same themes. Which takes us back to the question of learning. Why has this proved such a challenge?

Internal investigations

One of the explanations for the limited learning is the poor quality of many of the internal investigations. A trust’s internal investigation is invariably the first to be carried out. It usually takes place soon after the incident and is done by the organisation(s) providing the care and treatment. It is pivotal. A well-conducted internal investigation nails down the facts and unravels the complexities of the care and treatment. It is the first opportunity to establish any failings and to put them right. In short, it is the first and most important opportunity to learn and improve as it comes close on the heels of the incident and when the organisation is most likely to be receptive to change.

Unfortunately, the investigative process is largely a manual one and the quality of internal investigations varies greatly. Verita’s independent investigations into homicides has revealed how weak the analysis of care and treatment often is.

What next?

What are the likely implications of the decision to carry out fewer independent investigations? I believe there are several.

1. Firstly, families and carers will continue to seek answers when a relative is killed by someone in the care of mental health services. And it is highly unlikely that they will be satisfied by a trust investigating itself. After all, this has not been the case in the past. Consequently, internal investigations will continue to come under fierce scrutiny.
2. Politicians/government ministers are likely to be drawn back into discussions about the care and treatment of perpetrators of homicides and find themselves adjudicating about the need for an independent investigation in individual cases. This is an almost unavoidable consequence of restricting these investigations.
3. Mental health providers will breathe a sigh of relief and then begin to realise that the change will place an even greater responsibility on them to conduct a rigorous, detailed and balanced internal investigation. They will need to do this in a timely way. This will prove a formidable challenge. There is no standardised approach to investigating across the NHS. Frontline staff bear the brunt of the responsibility for doing the work and this is in addition to their day job as a clinician/nurse/manager.
4. Coroners will continue to look for assurance that service failings are being corrected to prevent future deaths.

Failure to identify the real problems and put them right remains an enduring issue in all investigative work in healthcare. It is one reason that Verita and Microsoft have worked together to develop Eva.

Written by Ed Marsden.

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