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.

Keywords:

• Serious incident
• review
• inquiry
• mental health services
• homicide

Acknowledgements

The authors gratefully acknowledge the contributions of the research participants. Thank you to Ruth Allen for her assistance with the analysis.

Authors contributions

Lillian Ng was responsible for the acquisition, analysis and interpretation of data of the data. All authors contributed to the concept of the work, critically revising the content of the article and approving the final version. The authors are jointly responsible for the accuracy and integrity of the work.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The authors report direct access to the study data. Access to transcripts of interviews with participants is ongoing and stored in accordance with New Zealand ethics committee guidelines. The analysed data is provided and can be accessed via supplementary material.

Notes

1 New Zealand District Health Boards are responsible for providing or funding the provision of health services in their district.

2 The role of the New Zealand Health and Disability Commissioner is to promote and protect the rights of consumers. This includes the fair, simple, speedy, and efficient resolution of complaints.

Additional information

Funding

This research was supported by a Faculty Research Development Fund award from The University of Auckland [L.N., grant number 3715260].