Review of the Findings of Some Homicide Mental Health Inquiries Since 1994
| Date | 01 June 2004 |
| DOI | https://doi.org/10.1108/13619322200400018 |
| Published date | 01 June 2004 |
| Pages | 28-30 |
| Author | Jane Mackay |
| Subject Matter | Health & social care |
Review of the Findings of
Some Homicide Mental Health
Inquiries Since 1994
Jane Mackay
Independent Health Consultant
Extra Curriculum
he purpose of an inquiry is to improve
practice and secure the future safety of patients and the
public through the translation of findings into improved
practice.
In December 1992, Christopher Clunis killed
Jonathan Zito, a young musician, at London’s Finsbury
Park tube station. The subsequent trial was front-page
news, and when Christopher Clunis was sentenced and
committed to Rampton Hospital, Jonathan Zito’s widow,
Jayne, called for a public inquiry. Subsequently the two
regional health authorities concerned commissioned an
independent inquiry in which I was involved. The
inquiry, although not held in public, generated a vast
amount of publicity and resulted in the Department of
Health issuing guidance, HSG(94/27), which is still
extant.
The whole process led to a change in attitudes to
mental health services for everyone and also heralded a
more open approach to working with families. Since
then I have been involved in almost 30 such inquiries
and have had the privilege to chair some of them. This
article is a result of this work; I have set in context the
process adopted and attempted to draw out the findings
and implications for the delivery of mental health
services.
Inquiry process
The remit of an HSG(94/27) inquiry is not about
scapegoating or blaming but about learning lessons for
the ‘safer’ delivery of mental health services. The scope
of the inquiry must be clearly defined by the terms of
reference, which should be succinct and reflect the aims
of the inquiry while taking into account the nature of
the incident(s), relevant legislation and the local
circumstances. It is important that there is no ambiguity.
The inquiry considers to what extent the care was in
line with statutory obligations, Department of Health
Tguidance and local policies and procedures. A view is
formed about the exercise of professional judgement
and the adequacy of any care plan, and takes into
account that effective care in the community is
dependent on good communications between a variety
of agencies working together.
Membership
When the guidance was first published there was an
understanding that a lawyer/barrister would chair such
an inquiry. However experience shows that what is
really required is a person who is aware of the sensitive
nature of such work and has good interpersonal and
writing skills. It is helpful for the inquiry team to have
experience that is relevant to the issues that will be
raised – for example, inner-city/rural aspects of care and
networking. It is also important that the inquiry carries
credibility with all the agencies involved and, again, the
choice of panel members is pertinent here. It is
imperative that all members of the inquiry team are
absolutely clear of their remit and of the depth of the
inquiry.
If the inquiry is likely to attract extensive media
coverage consideration might be given to the
engagement of a suitably eminent person to chair it.
Management and accountability
A senior staff member of sufficient experience and
authority is required to manage the inquiry, which is
likely to be time-consuming and to impact on existing
workloads. The prime functions of this person are to:
■co-ordinate the process
■liaise with the families, both of the victim and
the perpetrator
■support the inquiry team by ensuring all
appropriate documentation is available.
28 The Mental Health Review Volume 9 Issue 2 June 2004 ©Pavilion Publishing (Brighton) 2004
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