Qualitative study of district health board inquiries into mental health related homicide in a New Zealand sample

Abstract

The aim of this study is to identify the methods and content of hospital-based serious incident reviews involving mental health related homicide where a service user was the perpetrator between 2007 and 2017. Eleven reports were obtained from mental health services in New Zealand’s largest city and thematically analysed. Nine used the London protocol to identify clinical and system factors that may have contributed to the serious incident, but there was considerable variation in the way in which it was applied. Feedback to services was inconsistent. The voices of family members of the victims were largely absent and consideration of cultural context was missing. A structured protocol to specifically address the mental health context in New Zealand and internationally could resolve some of these issues and lead to a process that is more likely to provide comprehensive coverage of relevant matters and produce clear recommendations to effect improvements to services.

Keywords:

• mental health
• inquiry
• healthcare system
• homicide
• serious incident
• London protocol
• quality assurance

Ethical standards

Declaration of conflicts of interest

Lillian Ng has declared no conflicts of interest.

Alan F. Merry has declared no conflicts of interest.

Ron Paterson has declared no conflicts of interest.

Sally N. Merry has declared no conflicts of interest.

Ethical approval

The article does not contain any studies with human participants or animals performed by any of the authors.

Acknowledgements

The authors would like to thank Dr Ruth Allen for her assistance with the analysis.

Notes

1 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 work was supported by the University of Auckland Faculty of Medical and Health Sciences under a faculty research development grant (no. 3715260).