Mental health tragedies: investigating beyond human error

Abstract

The Department of Health is introducing a mandatory reporting system for adverse events in the NHS which will replace the statutory inquiries held when someone with a mental illness commits a homicide. This is part of a radical transformation in the way that errors and adverse outcomes are investigated and in the types of solutions that will be sought. Inquiries after homicides have typically investigated whether there was an error or omission by professionals involved in the care of the perpetrator that was causally significant. If human error is identified, then the inquiry team tends to see it as a sufficient explanation and the investigation ends. Experience in other fields has found that such limited investigations do not produce effective lessons for preventing future tragedies. It is necessary to regard human error as a symptom not a cause and ask why that person performed that action in those circumstances. In particular, one can examine the systemic factors acting on the professional and consider whether they made a mistake more likely. This article shows how radically different this change is and contrasts it with the current procedure of inquiries. It is argued that the new approach holds the promise of more effective learning but it requires major developments in research design. It also requires a fundamental cultural change in the NHS to a more open organization where errors or mistakes (the raw data of the system) can be reported without fear of retribution. The obstacles to achieving this are discussed.

Keywords:

• human error
• adverse events
• inquiries after homicides
• mandatory reporting system
• mental health standards