Inquiry into homicides by psychiatric patients: systematic audit should replace mandatory inquiries

Inquiries into homicides committed by psychiatric patients are currently mandatory under Department of Health guidance. They are often broadly defined in their terms of reference and almost always address not only the cause of the incident but also professional skill, practice, and culpability. Concurrent pursuit of both purposes is unlikely to maximise "learning from experience." Also, since inquiries can set their own thresholds for culpability, doctors can potentially be judged to a higher standard than would be required by the General Medical Council or negligence law. Lack of strict legal process increases the inherent potential unfairness to doctors. Investigation of cause and culpability should be separated and inquiries restricted to the former. There should also be a standing secretariat for inquiries to set terms of reference and to collate and distribute findings of inquiries. Widespread mandatory systematic audit of professional practice and service efficiency concerning risk assessment and management should largely replace costly ad hoc mandatory inquiries after homicides.