Inquiries as instruments of learning – or of ritual?

The authors rightly critique the variability in inquiry methodology. That 77% of reports failed to use root cause analysis (RCA), yet 40% of those same inquiries censured internal mental health service investigations for not applying RCA, illustrates the epistemic incoherence that has dogged these investigations since their inception. The imposition of RCA – borrowed from aviation safety and industrial process management – onto mental health homicide inquiries was always an uneasy fit. ^{Reference Livingstone, Jackson and Priestley3} That its use remains inconsistent underlines the conceptual dissonance at the heart of these processes. ^{Reference Eastman4}

These inquiries were never intended, unlike the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), to systematically pool data on homicide characteristics and preventive strategies. Yet, despite their starkly contrasting methodologies, both this and previous reviews identify common demographic and situational characteristics across both approaches. The findings are clear: these homicides overwhelmingly resemble domestic homicides rather than the kind of stranger violence that dominates media discourse. Perpetrators are more likely to kill family members or close acquaintances in a domestic setting with a weapon to hand, rather than strangers in public with exotic weaponry. This is a crucial observation, given that it is often the less common cases – stranger homicides, multiple homicides, child homicides – that garner disproportionate media attention and shape public discourse on homicide. ^{Reference Brown, Hughes, McGlen and Crichton5}

The conundrum of impact

Despite the financial burden – over £1.1 million in a single year – there is little to suggest these inquiries precipitate meaningful service evolution. ^{Reference Deshpande, Sinclair, Tebbs and Baldwin1} Recommendations are overwhelmingly weighted towards policy changes, governance modifications and staff training – precisely the kinds of interventions that allow organisations to demonstrate compliance without substantive reform. The historical recurrence of the same recommendations ^{Reference Taylor and Gunn6} suggests that inquiries, as currently configured, function more as instruments of institutional reassurance than mechanisms of genuine service improvement.

A particularly striking finding is the discrepancy in diagnostic prevalence between mental health homicide inquiries and NCISH data. That independent inquiries report a higher prevalence of schizophrenia (52%) than NCISH (34%) suggests a selection bias in determining which cases warrant external review. If inquiries overwhelmingly scrutinise homicides committed by individuals with schizophrenia, they risk reinforcing public anxieties about this diagnosis, whilst failing to address broader risk factors, including those associated with personality disorder and substance misuse. ^{Reference McCulloch and Parker7}

What role for independent inquiries?

There is an argument to be made that the independent inquiry model, at least in its current form, has reached an epistemological impasse. That is not to say that external scrutiny lacks utility, but rather that a model that repeatedly identifies the same deficiencies without offering novel insights must be questioned.

Deshpande et al ^{Reference Deshpande, Sinclair, Tebbs and Baldwin1} propose greater methodological standardisation – an overdue recommendation. Beyond this, however, there is a need for more fundamental recalibration. A greater emphasis on systems analysis, incorporating human factors methodology, would represent progress. So too would a reframing of inquiries as tools for understanding service-wide pressures rather than post hoc exercises in individual attribution.

Perhaps most urgently, policymakers must confront the question of proportionality. The decision to convene an independent inquiry into a single case of homicide, often years after the event, needs to be weighed against the practical utility of such exercises. That homicides by individuals with mental illness have not increased despite decades of inquiries ^{Reference Szmukler8} suggests that these reviews have not demonstrably improved risk reduction.

Yet, there is one undeniable function these inquiries perform, albeit incidentally: taken together, they provide a fragmented but revealing historiography of psychiatric care in England over the past 30 years. They serve as an unintended chronicle of evolving mental health services, charting shifts in clinical practice, policy implementation and resource allocation. As such, they present a series of case histories that, whilst not necessarily causally linked to the tragic outcomes they examine, nonetheless expose systemic weaknesses, patterns of failure and recurring shortcomings in mental health governance.

If these inquiries continue, it should not be under the pretence that they are necessarily reducing risk, but rather in recognition that they offer, at the very least, a sustained if inadvertent analysis of the mental health system itself. If violence reduction is the aim, a more fundamental change is required: a synthesis with broader population violence reduction strategies. ^{Reference Crichton9} Moreover, any serious discussion about the future of these inquiries must also address the needs of secondary victims: primarily the families of victims, who look for and deserve answers, but also those involved in the care of the perpetrator whose professional competence is questioned in public.