Mental health tragedies: investigating beyond human error

REFERENCES

• Baron J 1988 Thinking and Deciding Cambridge: Cambridge University Press
   Google Scholar
• Beck U 1992 Risk Society: Towards a New Modernity London: Sage Publications
   Google Scholar
• Blom-Cooper 1996 Some Reflections on Public Inquiries In Peay, J. (ed.) Inquiries after Homicide, London: Duckworth
   Google Scholar
• Boeing Product Safety Organization 1993 Statistical Summary of Commercial Jet Aircraft Accidents; Worldwide Operations, 1959 – 1992 Seattle, WA: Boeing Commercial Airplanes
   Google Scholar
• Bolam v Friern Barnett Hospital Management Committee [1957] 1 WLR 582
   Google Scholar
• Carpy , D . 1989 . Tolerating the Counter-Transference: a Mutative Process . International Journal of Psychoanalysis , 70 : 287 – 94 .
   PubMed Web of Science ®Google Scholar
• Carson , D . 1996 . Developing Models of Risk to Aid Co-operaton between Law and Psychiatry? . Criminal Behaviour and Mental Health , 6 : 6 – 10 .
   Google Scholar
• Chapman H Ashman M Oyebode O Rogers P 1996 Report of the Independent Inquiry into the Treatment and Care of Richard Burton Leicester: Leicestershire Health Authority
   Google Scholar
• Cooper , J , Newbower , R and Kitz , R . 1984 . An Analysis of Major Errors and Equipment Failures in Anesthesia Management: Conditions for Prevention and Detection . Anasthesiology , 60 : 42 – 3 .
   Web of Science ®Google Scholar
• Crawford L Devaux M Ferris R Haywood P 1997 The Report into the Care and Treatment of Martin Mursell London: Camden and Islington Health Authority
   Google Scholar
• Department of Health 2000 An Organisation with a Memory London: The Stationery Office
   Google Scholar
• Department of Health 2001 Building a Safer NHS London: The Stationery Office
   Google Scholar
• Eastman N 1996 Towards an Audit of Inquiries: Enquiry not Inquiries In Peay, J. (ed.) Inquiries after Homicide, London: Duckworth pp.147 – 63
   Google Scholar
• Eldergill , A . 1999 . Reforming Inquiries following Homicides . Journal of Mental Health Law , 2 : 85 – 172 .
   Google Scholar
• Eldergill , A . 2002 . Is Anyone Safe? Civil Compulsion Under the Draft Mental Health Bill . Journal of Mental Health Law , 5 : 331 – 359 .
   Google Scholar
• Fischhoff , B . 1975 . Hindsight does not Equal Foresight: The Effect of Outcome Knowledge on Judgement Under Uncertainty . Journal of Experimental Psychology: Human Performance and Perception , 1 : 288 – 99 .
   Web of Science ®Google Scholar
• Forgas J (ed.) 1991 Emotion and Social Judgements Oxford: Pergamon Press
   Google Scholar
• Giddens A 1990 The Consequences of Modernity Cambridge: Polity Press
   Google Scholar
• Heimann , P . 1950 . On Counter-Transference . International Journal of Psycho-analysis , 31 : 81 – 4 .
   Web of Science ®Google Scholar
• Henkel M 1991 Government Evaluation and Change London: Jessica Kingsley
   Google Scholar
• Hood C Rothstein H Baldwin R 2000 The Government of Risk: Understanding Risk Regulation Regimes Oxford: Oxford University Press
   Google Scholar
• Kemeny J 1979 Report of the President's Commission on the Accident at Three Mile Island New York: Pergamon Press
   Google Scholar
• London Borough of Greenwich 1987 A Child in Mind: Protection of Children in a Responsible Society London: London Borough of Greenwich
   Google Scholar
• Maslach , C , Schaufeli , W and Leiter , M . 2001 . Job Burnout . Annual Review of Psychology , 52 : 397 – 422 .
   PubMed Web of Science ®Google Scholar
• McGrath , M and Oyebode , F . 2002 . Qualitative Analysis of Recommendations in 79 Inquiries after Homicide Committed by Persons with Mental Illness . Journal of Mental Health Law , Dec : 262 – 82 .
   Google Scholar
• Mishcon J Dick D Welch N Sheehan A Mackay J 1995 The Grey Report: Report of the independent inquiry team into the care and treatment of Kenneth Grey London: East London and the City Health Authority
   Google Scholar
• Munro , E . 1998 . Improving Social Workers' Knowledge Base in Child Protection Work . British Journal of Social Work , 28 : 89 – 105 .
   Web of Science ®Google Scholar
• Munro , E . 1999 . Common Errors of Reasoning in Child Protection Work . Child Abuse and Neglect , 23 : 745 – 58 .
   PubMed Web of Science ®Google Scholar
• Munro , E and Rumgay , J . 2000 . The Role of Risk Assessment in Reducing Homicides by People with Mental Illness . British Journal of Psychiatry , 176 : 116 – 20 .
   PubMed Web of Science ®Google Scholar
• Munro E forthcoming The Impact of Audit on Social Work Practice British Journal of Social Work
   Google Scholar
• NHS Executive 1994 Health Service Guidelines HSG (94) 27 London: Department of Health
   Google Scholar
• Oatley K Jenkins J 1996 Understanding Emotions Oxford: Blackwells
   Google Scholar
• Peay J (ed.) 1996 Inquiries after Homicide London: Duckworth
   Google Scholar
• Petch , E and Bradley , C . 1997 . Learning the Lessons from Homicide Inquiries: Adding Insult to Injury? . Journal of Forensic Psychiatry , 8 : 161 – 84 .
   Web of Science ®Google Scholar
• Power M 1997 The Audit Society Oxford: Oxford University Press
   Google Scholar
• Rasmussen , J . 1990 . Human Error and the Problem of Casuality in Analysis of Accidents . Philosophical Transactions of the Royal Society of London , 327 : 449 – 460 .
   PubMed Web of Science ®Google Scholar
• Reason P 1990 Human Error Cambridge: Cambridge University Press
   Google Scholar
• Reder P Duncan S 1999 Lost Innocents, A follow-up study of fatal child abuse London: Routledge
   Google Scholar
• Ritchie J Dick D Lingham R 1994 Report of the Inquiry into the Care and Treatment of Christopher Clunis North East Thames and South East Thames Regional Health Authorities, HMSO
   Google Scholar
• Rock P 1996 The Inquiry and Victims' Families In Peay, J. (ed.) Inquiries after Homicide, London: Duckworth pp. 101 – 19
   Google Scholar
• Rumgay , J and Munro , E . 2001 . The Lion's Den: Professional Defences against Anxiety . Journal of Forensic Psychiatry , 12 : 357 – 378 .
   Web of Science ®Google Scholar
• Shepherd D 1996 Learning the Lessons 2nd edn, London: The Zito Trust
   Google Scholar
• Simon H 1996 The Sciences of the Artificial Cambridge, Mass: The MIT Press
   Google Scholar
• Taylor , H and Gunn , J . 1999 . Homicides by People with Mental Illness: Myth and Reality . British Journal of Psychiatry , 174 : 9 – 14 .
   PubMed Web of Science ®Google Scholar
• Whittle , M . 1997 . Malignant Alienation . Journal of Forensic Psychiatry , 8 : 5 – 10 .
   Web of Science ®Google Scholar
• Wildavsky A 1988 Searching for Safety New Brunswick, NJ: Transaction Publishers
   Google Scholar
• Woods D Cook R forthcoming The Second Story
   Google Scholar
• Woods D Johannesen L Cook R Sarter N 1994 Behind Human Error: Cognitive Systems, Computers and Hindsight Wright-Patterson Air Force Base, Ohio: CSERIAC
   Google Scholar
• Wright , D , Mackenzie , S , Buchan , I , Cairns , C and Price , L . 1991 . Critical Incidents in the Intensive Therapy Unit . Lancet , 338 : 676 – 8 .
   PubMed Web of Science ®Google Scholar