Mental health homicide inquiry delays ‘allow risky practice to continue’

Seven years. That’s how long it took the NHS to set up and publish an independent review (released in May) into the killing of support worker Ashleigh Ewing by a man who had been in contact with mental health services.

Ewing died in 2006 after being stabbed to death by Ronald Dixon. At the time of the offence Dixon had been receiving care from Northumberland, Tyne and Wear NHS Foundation Trust.

The delay in the publication of the independent investigation into Dixon’s NHS care drew criticism. But waits of several years for inquiries to be published are not uncommon despite official guidance insisting that publication should “take place as soon as possible” after an incident.

An analysis of almost 400 cases by Dave Sheppard, a former social worker who now runs the MHA and MCA Law training service, reveals a stark disparity in the time taken by the NHS to publish independent reviews of homicide cases.

In 2013 alone, the average delay has been over four years. The time passed between homicide incidents and independent reviews being published ranged from 18 months, to seven and a half years. Looking further back, one case in 2006 took 10 and a half years.

So why are some inquiries taking so long? The NHS points to the fact that independent investigations cannot be published until legal proceedings have concluded in homicide cases. But families of homicide victims dispute that this is justification for such lengthy delays.

Documentary maker Julian Hendy’s father was killed in a mental health homicide incident in 2007. Hendy now runs the hundred families support organisation for other families who have lost loved ones in homicide cases.

“They cannot publish inquiry findings until legal proceedings have closed but they can commission the inquiry, get the team in place, collect the records and line-up who they are going to interview,” says Hendy.

“Using it as an excuse for delays of years is rubbish. Look at Winterbourne View. It took 15 months from start to finish. It was a complicated case and there were prosecutions going on. The Independent Police Complaints Commission investigation into the Nicola Edgington case took 18 months, they published almost immediately after the court case was finished. So it can be done with the right will,” he adds.

Until recently, responsibility for independent mental health homicide inquiries lay with Strategic Health Authorities – the regional NHS bodies that were made defunct in April this year under the coalition’s NHS reforms. Now the investigations are part of the remit of NHS England.

The national NHS agency told Community Care it is in the process of developing a new “single operating model” for mental health homicide inquiries.

Hendy has given feedback to NHS England on the process and says there “are some good people” on their project team. He’s adamant that any new system needs to be “timely, it needs to be independent and it needs to be accountable.”

A big frustration is that there is “very little evidence” that the NHS learns from adverse incidents, says Hendy. He looked at a number of mental health homicide inquiries at one mental health trust and found that the “same recommendations” kept cropping up.

“Time and time again you’d see issues around care planning, risk management, care records. Each time someone within the trust would say ‘things have changed’ and then the next one comes along. It’s publicity and they are keen to spin a good story, but what they need to demonstrate is that people are learning from these things,” he says.

Other issues raised by Hendy include a lack of engagement with families in the inquiry process. Official guidance says that the needs of families should be a “primary concern” in investigations. But an analysis of over 100 cases by hundred families found that there had been no family involvement in 39% of investigations.

In Hendy’s view there is also a lack of oversight nationally to check up on the progress of inquiries, or indeed whether the ‘action plans’ that come out of them are fit for purpose.

“While these things aren’t investigated properly, dangerous or risky practices are allowed to continue,” he says.

A spokesperson for NHS England told Community Care that “avoidable delays are unacceptable” and confirmed that a new system for investigating mental health homicides is in the pipeline.

“It will be a single operating model which will ensure a consistent approach across the whole of England. We think it is paramount for families to be engaged throughout the process and our new system will include principles to involve families during the different stages of investigations,” said the spokesperson.

“We are also focussing on strategic learning and through NHS commissioning arrangements will robustly hold Trusts to account in implementing their action plans.”