The conduct of inquiries: a qualitative study of the perspectives of panel members who investigate mental health related homicide

Abstract

Background Inquiries into mental health related homicides may be held to identify failures in care and areas for improvement, accountability and to enhance public confidence. However, inquiries do not always achieve these aims. Aim The aim of this study was to explore the perspectives of members of inquiry panels who conduct inquiries into mental health related homicides in order to identify elements that would constitute a good inquiry. Methods We selected a sample of inquiry panel members comprising 15 senior clinicians, legal experts and consumer advisors. Semi-structured interviews were audio-recorded, transcribed and analysed using thematic analysis. Results Participants raised concerns related to: (1) orientation of the panel to the inquiry task; (2) clarity of the process; and (3) impact of the inquiry. Most participants recognised that inquiries require a focus on mental health systems and sensitivity to families and clinicians. They reported difficulties in clarifying purposes, attending to cultural aspects of the case, having a clear method tailored to the mental health context, formulating recommendations and disseminating findings. Conclusions Our participants perceived a number of weaknesses in the process by which inquiries into mental health related homicides had been conducted, and recommendations formulated and implemented. There is an opportunity to address these and thereby potentially improve the effectiveness and value of inquiries.