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Risk management and system failure analysis in mental health investigations 

Author: Tony Ryan a
Affiliation:   a The Health & Social Care Advisory Service & University of Manchester.
DOI: 10.1080/13698570412331323207
Publication Frequency: 6 issues per year
Published in: journal Health, Risk & Society, Volume 6, Issue 4 December 2004 , pages 303 - 305
Formats available: PDF (English)
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Abstract

This editorial explores the way in which mental health investigations are developing in England and in particular those involving a homicide. A move away from traditional panel inquiries and towards investigations using root cause analysis (RCA) is aimed at shifting the focus from individual blame to identifying system failure. Thus it is envisaged by policy makers that the RCA approach will offer greater learning opportunities for mental health services. The key difficulties associated with panel inquiries are highlighted before describing the intended benefits of the RCA approach. Finally, five key areas where systematic research can support the development of this approach are suggested.
Keywords: homicide; homicide inquiries; mental health; risk; root cause analysis; system failure analysis
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