References
- Amos, T., Appleby, L., & Shaw, J. (1997). National confidential inquiry into suicide and homicide by people with mental illness: Recent developments. International Journal of Psychiatry in Clinical Practice, 1(1), 69–71. https://doi.org/https://doi.org/10.3109/13651509709069207
- Berwick, D. M. (2003). Errors today and errors tomorrow. New England Journal of Medicine, 348(25), 2570–2572. https://doi.org/https://doi.org/10.1056/NEJMe030044
- Bowden, P. (1995). Confidential inquiry into homicides and suicides by mentally ill people. A preliminary report on homicide. Psychiatric Bulletin, 19(2), 65–66. https://doi.org/https://doi.org/10.1192/pb.19.2.65
- Bowers, L., Allan, T., Simpson, A., Nijman, H., & Warren, J. (2007). Adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: The Tompkins Acute Ward Study. International Journal of Social Psychiatry, 53(1), 75–84. https://doi.org/https://doi.org/10.1177/0020764007075011
- Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/https://doi.org/10.1191/1478088706qp063oa
- Buchanan, A. (1999). Independent inquiries into homicide. British Medical Journal, 318(7191), 1089–1090. https://doi.org/https://doi.org/10.1136/bmj.318.7191.1089
- Chaplow, D. (2004). Walking the tightrope: Perception, fact and inquiry. Australasian Psychiatry, 12(4), 320–324. https://doi.org/https://doi.org/10.1080/j.1440-1665.2004.02120.x
- Crichton, J. H. M. (2011). A review of published independent inquiries in England into psychiatric patient homicide, 1995–2010. Journal of Forensic Psychiatry & Psychology, 22(6), 761–789. https://doi.org/https://doi.org/10.1080/14789949.2011.617832
- Dekker, S. W. A., & Breakey, H. (2016). ‘Just culture:’ Improving safety by achieving substantive, procedural and restorative justice. Safety Science, 85, 187–193. https://doi.org/https://doi.org/10.1016/j.ssci.2016.01.018
- Dixon-Woods, M., & Pronovost, P. J. (2016). Patient safety and the problem of many hands. BMJ Quality Safety, 25(7), 485–488. https://doi.org/https://doi.org/10.1136/bmjqs-2016-005232
- Donaldson, L. (2002). An organisation with a memory. Clinical Medicine, 2(5), 452–457. https://doi.org/https://doi.org/10.7861/clinmedicine.2-5-452
- Eastman, N. (1996). Inquiry into homicides by psychiatric patients: Systematic audit should replace mandatory inquiries. British Medical Journal, 313(7064), 1069. https://doi.org/https://doi.org/10.1136/bmj.313.7064.1069
- Francis, R. (2013). Lessons from Stafford. Medico Legal Journal, 81(4), 153–165. https://doi.org/https://doi.org/10.1177/0025817213513125
- Grounds, A. (1997). Commentary on “Inquiries: Who needs them?” Psychiatric Bulletin, 21(3), 134–135. https://doi.org/https://doi.org/10.1192/pb.21.3.134
- Holliday, E., & Taylor, P. J. (2015). Consequences for clinicians and mental health services of a homicide by a current or recent patient: A European Union (EU) wide survey. International Journal of Forensic Mental Health, 14(3), 218–229. https://doi.org/https://doi.org/10.1080/14999013.2015.1075627
- House of Commons Public Administration Select Committee. (2015). Investigating clinical incidents in the NHS. The Stationery Office Limited.
- Leape, L. L., Woods, D. D., Hatlie, M. J., Kizer, K. W., Schroeder, S. A., & Lundberg, G. D. (1998). Promoting patient safety by preventing medical error. JAMA, 280(16), 1444–1447. https://doi.org/https://doi.org/10.1001/jama.280.16.1444
- Liamputtong, P. (2013). Qualitative research methods (4th ed.). Oxford University Press.
- Lingham, R., & Murphy, E. (1996). Mental health inquiries. Deadly serious. Health Service Journal, 106(5527), 22–23.
- Lowe, M. R. (2003). In defence of inquiry panels. Psychiatric Bulletin, 27(10), 395. https://doi.org/https://doi.org/10.1192/pb.27.10.395
- Mackay, J. (2004). Review of the findings of some homicide mental health inquiries since 1994. Mental Health Review Journal, 9(2), 28–30. https://doi.org/https://doi.org/10.1108/13619322200400018
- Macrae, C. (2016). The problem with incident reporting. BMJ Quality Safety, 25(2), 71–75. https://doi.org/https://doi.org/10.1136/bmjqs-2015-004732
- McGrath, M., & Oyebode, F. (2002). Qualitative analysis of recommendations in 79 inquiries after homicide committed by persons with mental illness. Journal of Mental Health Law, 262–282.
- Newdick, C., & Danbury, C. (2015). Culture, compassion and clinical neglect: Probity in the NHS after Mid Staffordshire. Journal of Medical Ethics, 41(12), 956–962. https://doi.org/https://doi.org/10.1136/medethics-2012-101048
- Ng, L., Merry, A. F., Paterson, R., & Merry, S. N. (2020). Families of victims of homicide: Qualitative study of their experiences with mental health inquiries. British Journal of Psychiatry Open, 6, e100. https://doi.org/https://doi.org/10.1192/bjo.2020.84
- Ng, L., Merry, S., Paterson, R., & Merry, A. F. (2020). Mental health inquiries in the case of homicide. Psychiatry Psychology and Law, 27(5), 1–18. https://doi.org/https://doi.org/10.1080/13218719.2020.1751329
- NHS. (2015). Serious incident framework. Supporting learning to prevent recurrence. NHS.
- O'Connor, C., & Joffe, H. (2020). Intercoder reliability in qualitative research: Debates and practical guidelines. International Journal of Qualitative Methods, 19, 1–13.
- Paterson, R. (2008). Inquiries into health care: Learning or lynching? New Zealand Medical Journal, 121(1286), 100–115. https://doi.org/https://doi.org/10.1080/121-1286/3376/
- Petch, E., & Bradley, C. (1997). Learning the lessons from homicide inquiries: Adding insult to injury? The Journal of Forensic Psychiatry, 8(1), 161–184. https://doi.org/https://doi.org/10.1080/09585189708412002
- Reason, J. (1998). Achieving a safe culture: Theory and practice. Work & Stress, 12(3), 293–306. https://doi.org/https://doi.org/10.1080/02678379808256868
- Reeves, S., Ross, F., & Harris, R. (2014). Fostering a "common culture"? Responses to the Francis Inquiry demonstrate the need for an interprofessional response. Journal of Interprofessional Care, 28(5), 387–389. https://doi.org/https://doi.org/10.3109/13561820.2014.921985
- Reiss, D. (2001). Counterfactuals and inquiries after homicide. The Journal of Forensic Psychiatry, 12(1), 169–181. https://doi.org/https://doi.org/10.1080/09585180010027914
- Reith, M. (1998). Risk assessment and management: Lessons from mental health inquiry reports. Medicine, Science and the Law, 38(3), 221–226. https://doi.org/https://doi.org/10.1177/002580249803800307
- Ritchie, J., Lewis, J., Nicholls, C. M., & Ormston, R. (2013). Qualitative research practice: A guide for social science students and researchers. SAGE.
- Rock, P. (1996). The inquiry and victims' families. In J. Peay (Ed.), Inquiries after homicide (pp. 101–119). Gerald Duckworth & Co Ltd.
- Rose, N. (2000). Six years' experience in Oxford. Psychiatric Bulletin, 24(7), 243–246. https://doi.org/https://doi.org/10.1192/pb.24.7.243
- Runciman, W. B., Merry, A. F., & Tito, F. (2003). Error, blame, and the law in health care—An antipodean perspective. Annals of Internal Medicine, 138(12), 974–979. https://doi.org/https://doi.org/10.7326/0003-4819-138-12-200306170-00009
- Sharpe, V. A. (2003). Promoting patient safety: An ethical basis for policy deliberation. The Hastings Center Report, 33(5), S3. https://doi.org/https://doi.org/10.2307/3528637
- Simpson, A. I., Allnutt, S., & Chaplow, D. (2001). Inquiries into homicides and serious violence perpetrated by psychiatric patients in New Zealand: Need for consistency of method and result analysis. Australian and New Zealand Journal of Psychiatry, 35(3), 364–369. https://doi.org/https://doi.org/10.1046/j.1440-1614.2001.00894.x
- Szmukler, G. (2000). Homicide inquiries: What sense do they make? Psychiatric Bulletin, 24(1), 6–10. https://doi.org/https://doi.org/10.1192/pb.24.1.6
- Taylor, P. J. (2007). Decline of the English inquiry. Criminal Behaviour Mental Health, 17, 69–74. https://doi.org/https://doi.org/10.1002/cbm.650
- Taylor-Adams, S., & Vincent, C. (2004). Systems analysis of clinical incidents: The London protocol. Clinical Risk, 10(6), 211–220. https://doi.org/https://doi.org/10.1258/1356262042368255
- Thompson, D. F. (1980). Moral responsibility of public officials: The problem of many hands. American Political Science Review, 74(4), 905–916. https://doi.org/https://doi.org/10.2307/1954312
- Tidmarsh, D. (1997). Psychiatric risk, safety cultures and homicide inquiries. The Journal of Forensic Psychiatry, 8(1), 138–151. https://doi.org/https://doi.org/10.1080/09585189708412000
- Vincent, C., Stanhope, N., & Taylor-Adams, S. (2009). Developing a systematic method of analysing serious incidents in mental health. Journal of Mental Health, 9(1), 89–103. https://doi.org/https://doi.org/10.1080/09638230016985
- Vincent, C., Taylor-Adams, S., Chapman, E. J., Hewett, D., Prior, S., Strange, P., & Tizzard, A. (2000). How to investigate and analyse clinical incidents: Clinical risk unit and association of litigation and risk management protocol. BMJ, 320(7237), 777–781. https://doi.org/https://doi.org/10.1136/bmj.320.7237.777
- Walshe, K., & Higgins, J. (2002). The use and impact of inquiries in the NHS. British Medical Journal, 325(7369), 895. https://doi.org/https://doi.org/10.1136/bmj.325.7369.895
- Warner, J. (2006). Inquiry reports as active texts and their function in relation to professional practice in mental health. Health, Risk & Society, 8(3), 223–237. https://doi.org/https://doi.org/10.1080/13698570600871661