How to conduct a post homicide or suicide inquiry

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  • INDEPENDENT INQUIRIES Anselm Eldergill British Journal of Health Care Management, May 1999, pp.198203INTRODUCTIONHealth Service Guidelines require Health Authorities to hold an independent inquiry in cases wherea psychiatric patient kills someone (HSG(94)27). A purely internal investigation will likewise beinappropriate if an incident, or series of incidents, calls into question existing procedures (BuildingBridges, pp.8081). Such inquiries involve a great deal of work and are a daunting prospect foranyone who has not previously had to arrange one, the more so because no legislation ordepartmental guidelines have been issued which prescribe or recommend particular procedures.This article aims to guide managers through the process, and it includes precedents which theycan use or adapt , such as terms of reference and job descriptions. Because the conduct of allinquiries involves applying certain universal principles, and taking certain common steps, theprocedures described below will also be useful for managers working outside psychiatry. Theviews and suggestions expressed in this article are those of the author. They are EldergillProcedures, and Health Authorities, and the chairmen of independent inquiries, are in no sensebound by them.GENERAL PRINCIPLESAn inquiry is a learning tool: its purpose is to learn any lessons which may minimise the possibilityof a recurrence of the tragic event, which is why the report is made to the bodies that have powerto change the way the service is provided. The outcome should be that any feasible improvementsare made, for the future good of everyone.The focus of the inquiry is the care and treatment of a particular patient, rather than the triggeringevent itself, so that the allocation of blame can only ever be an incidental effect of the inquiryprocess. As regards the treatment and care provided immediately prior to the homicide, theconcern is with causation, not culpability. Retribution, and the expiation of wrong-doing, arematters for the civil and criminal courts and for professional disciplinary bodies. Moreover, unlessinsane at the time, the patient is responsible for his act, not the professionals who tried to helphim. Nor can there be any presumption that the fact of the homicide is evidence of poor treatmentor care. The occurrence of such a tragedy does not per se demonstrate any error of judgement onthe part of those discharging or supervising the patient. Even a very low risk, such as winning thelottery, from time to time becomes an actuality.Apprehension and fear on the part of those taking part must be minimised, so that the inquirydoes not interfere with the service being provided to other patients. Public inquiries inevitablyinvolve confrontation and those attending are often inhibited from being candid with the panel. Aprivate hearing is therefore to be preferred. The use of terms such as hearing, witness andevidence should be confined to the procedural part of the terms of reference. In other contexts, itis less inhibiting to refer to meetings and discussions with those involved in the inquiry. Indeed,referring to the process as a service review, rather than as an inquiry, may be moreconstructive.Given the usual remit, the problem is how to achieve procedural fairness in a process of decision-making which involves commenting on professional conduct or, very rarely, criticising it. Theessential requirement is that the inquiry should be fair and just and be seen to be fair and just.This requires providing some degree for protection to individuals whose credibility is stronglyimpugned, and protecting them from unfair attack or condemnation. Subject to this overriding 1
  • principle of fairness, an inquiry must balance various needs: thoroughness, speed, economy, andinformality. F amily members, carers and victims should be kept informed of the progress of theinquiry and be supported by an independent person or organisation. They should be told thecontent of any press releases before the information is made public. The Health Authority shouldconsider reimbursing the legal fees of family members if they wish to be accompanied to thehearing by a lawyer.THE COMMISSIONING AGENCIESAlthough it is the relevant Health Authority that is required to hold the independent inquiry, it isnot uncommon for the local social services authority to be a joint commissioner. In such cases, thesocial services authority will need to be a joint partner from the outset, agreeing the terms ofreference, panel appointments and financial arrangements. The appointment of an inquiry steeringcommittee, comprising a representative from each authority together with the inquiry chairmanand clerk, helps to ensure good co-ordination and communication.APPOINTING A CHAIRMAN OF THE INQUIRYThe first step is for the Health Authority, in consultation with the local social services authority, toappoint a legal chairman of the inquiry. The chairmans functions are clear from the following jobdescription, which should be annexed to his letter of appointment. It is particularly important thatthe chairman has authority to make decisions in between meetings of the panel members, ifunnecessary delays are to be avoided. Role of the Legal Chairman of the Inquiry The principal functions of the legal chairman are as follows: 1. To ensure that the inquiry is conducted in accordance with the terms of reference. 2. To chair meetings of the panel members and the private hearings at which oral evidence is given. 3. To ensure that the inquiry is conducted fairly, that is in a manner which is consistent with the principles of natural justice. 4. To provide guidance to the other panel members, and to witnesses who give oral or written evidence, on matters of law. 5. To take all decisions about the conduct of the inquiry prior to, or between, meetings of members of the inquiry panel. 6. To inspect, and decide how to respond to, all documents and correspondence submitted to the panel of inquiry (other than correspondence of a purely administrative nature). 7. To be responsible for the drafting of the final report, and to approve the final report. 8. To draft (1) the case chronology summarising the relevant history; (2) any Salmon-type letter, identifying heads of evidence upon which it is thought that the witness may assist the inquiry; (3) any letter to a witness with which is enclosed a part of the draft report containing criticisms of her/him; (4) the letter to the Health Authority which accompanies the draft report; (5) any letters to persons whose interests may be adversely affected by the reports publication. 9. To draft or approve all other documents and correspondence sent out by or on behalf of the panel of inquiry, other than correspondence of a purely administrative nature. 2
  • 10. Following consultation with the clerk to the inquiry, to set a timetable for each inquiry. 11. As soon as reasonably practicable, to meet with staff involved in the care or treatment of the patients into whose cases the panel is inquiring. 12. Where considered necessary or desirable by her/him, to consult the other panel members and the clerk to the inquiry about any decision concerning the conduct of the inquiry.The authorities should provide the chairman with a detailed information pack concerning theorganisation of local health and social services. The Health Authority should also write to thepatient and the deceaseds next-of-kin, advising them that an inquiry has to be held, and seekingthe patients consent, via his solicitors, to the release of relevant records. It is necessary to takethis action as soon as possible, subject to the possible caveat that the criminal court papersshould not be sought until after the conclusion of those proceedings (see below). The chairmanwill need to be kept regularly informed about how these criminal proceedings are progressing.This is particularly important if the case has been well publicised, because of the need to plan aresponse to press coverage of the trial or sentencing hearing. Having appointed the chairman, thetwo authorities can then agree the terms of reference with him.AGREEING TERMS OF REFERENCEThe terms of reference should direct attention away from the how and why of the homicide to themore general issues of patient treatment and care. To this end, they should begin with a statementsetting out the ethos and purpose of the inquiry, emphasising that the inquiry process is supposedto be constructive, and that the inquiry panel will do all it can to reduce anxiety amongstparticipants. They should then go on to specify the inquiry panels remit and the procedure to beadopted by the panel. The terms should be enclosed with the letters of appointment. Generalissues to be considered at this stage are confidentiality (the extent to which an undertaking shouldbe given not to include information about the patient or his family in the inquiry report); whetheror not it is productive to ask witnesses to affirm; whether anonymity should only be offered tothose professionals who assist the inquiry; whether employees contracts of employment requirethem to co-operate with the inquiry; and whether the final report will be published. BuildingBridges states that undertaking to publish the repo