Fragmented mental health services and failure to learn creates risks of violent homicides

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Fragmented mental health services and a failure to learn from mistakes is increasing the risk of homicides committed by people with serious mental health issues, an NHS report has warned.

There were 111 homicides committed by people receiving mental health services in the year to 19 March and a new report by NHS England warns the lack of joined-up services, poor communication and poor access to crisis care for seriously ill people were all factors in the killings.

It comes as research shows the proportion of homicides committed by mental health patients, while extremely rare, is rising as a share of overall killings. Up to March 2019 homicides committed by a person with mental health problems made up a sixth of the 671 total that year.

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This is despite NHS England scrapping funding to research the problem last year.

The Hundred Families charity, which supports families whose loved ones have been killed by someone with a serious mental illness, has criticised the repeated failure to learn from investigation reports which make the same warnings year after year.

Julian Hendy’s 75-year-old father Philip was stabbed and killed in 2007 by a psychotic man with a long history of mental health problems and who was being treated by the NHS.

Mr Hendy, who runs Hundred Families, told The Independent: “The NHS is not an organisation with a memory. The same problems in care keep happening, we’ve had 26 years of these reviews and we still keep seeing the same things. How many times do people need to be told?”

He added: “My fear is that some mental health trusts and the regulators see it as a tick-box exercise rather than really learning what has gone wrong and putting it right.”

He believed there was a “cultural problem”, saying: “There seems to be a view that admitting someone to hospital is a failure. There is such a high bar to receiving treatment it only happens when people do something very seriously wrong.”

Following a mental health homicide the NHS is required to commission an independent investigation. During 2018-19 a total of 168 were being carried out.

In the latest annual report, published by NHS England this week, it warned: “There is a risk that future deaths will not be reduced due to ineffective learning from regional and national system, policy or practice issues or omissions and recurrent themes.”

Key themes from reports into mental health homicides included:

A disconnect between mental health and physical health services; The separation of mental health and drug abuse services which resulted in a narrow focus and misdiagnosis or inappropriate treatment; A lack of a coordinated approach and continuity of care, especially for complex patients; Poor access to crisis care and in-patient hospital wards; A failure to share information about patients, to complete risk assessments and consider historical risks; Families’ concerns not being acted on or considered; and A general lack and poor quality of communication between agencies despite known risks

Mr Hendy said a lot of problems were the result of how services were organised saying: “We need to recognise mental health is not nine to five. People don’t only get ill during office hours.

“Funding is part of it but not all of it. Better care and treatment could have avoided what happened in a lot of cases.”

He added: “There is so much emphasis on prevention of suicide but there is no funding for the prevention of homicide by mental health patients.”

The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) is commissioned by NHS England to collect data and research deaths.

Last year it emerged NHS England had cut funding for the NCISH to collect and analyse data on patient homicides but did maintain funding for suicide prevention.

Since 1997 it found half of patients who committed homicides were not receiving care as intended and patients were also at high risk of being victims of homicide.

Professor Louis Appleby, director of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, told The Independent: “It’s too simple to say that the NHS doesn’t learn. One of the reasons we seem not to learn is that the messages from inquiries are already familiar. Just as important is to ask why the NHS – often skilled senior staff – don’t do the things they know to be beneficial.”

He said one problem was a focus on prediction and trying to identify people who may commit homicide.

“All our evidence shows most perpetrators are viewed as low risk. So we should stop talking the language of prediction and ensure safer care for all.

“Our evidence shows the two key elements are addressing drug and alcohol use and ensuring patients receive the care as planned, ie, supervision and medication. It’s very unusual for a patient to commit a homicide unless their illness is complicated by one of two things – substance misuse or lack of follow-up and treatment.”

Most homicides occurred when patients were receiving services within the community; in 72 per cent of cases the killer was known to the victim and in 69 per cent of cases they had a history of violence.

Dr Adrian James, president of the Royal College of Psychiatrists, said: “Homicides committed by those receiving support from mental health services are rare tragedies, but have devastating consequences for the families of both victim and perpetrator.

“Although people living with serious mental illness are more likely to harm themselves than someone else, it is vital that services learn from these incidents to improve both patient and public safety.

“Risk assessments should be carried out at the earliest opportunity and be shared with relevant teams, agencies and services. This will ensure patients receive the most appropriate care and support for their illness, while reducing the risk to the public.”

In its report NHS England said more work was needed to make sure lessons from investigations were learned and reports produced quickly with “dissemination of meaningful learning across the wider system”.

A spokesperson added: “While each case is a tragedy for the individual families involved, these are extremely rare events.

“The NHS is committed to learning from the findings of all independent investigations and it is precisely why this annual report has been published and the recommendations will be examined and taken forward where appropriate, locally and nationally.”

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