We need an inquiry, not an inquisition

Collective shock and outrage accompanied James Coates' heartrending account of the devastating impact of the death of his father, Ian, along with the other victims stabbed by Valdo Calocane in Nottingham last year. Calocane was given an indefinite hospital order in January after pleading guilty to three counts of manslaughter on the grounds of diminished responsibility. He was diagnosed with paranoid schizophrenia, which experts agreed caused him to perpetrate the killings. Last week, the Care Quality Commission (CQC) report found that a "series of errors and misjudgements" in his care led to his discharge, despite his repeatedly not taking medication and showing signs of aggression in the months leading up to the tragic events. The families of the victims have confirmed that a public inquiry will take place.

Undoubtedly, an aspect of this catastrophe relates to inadequacies in service provision. Anyone working with people suffering with mental health problems will recognise the challenges of getting a person who shows clear signs of risk seen by frontline psychiatric services. The CQC report documents the attempts of Calocane's family to contact Nottingham NHS Trust to share their concerns about his deteriorating mental state, only to meet with a closed door. This is also all too familiar.

Despite improved focus upon mental health, provision remains variable. Overstressed, over-demanded professionals have the impossible job of allocating scarce resources, sometimes to individuals who suffer with the delusion that they are sane and thus not in need of treatment. Often clinicians sadly regard their primary task to be the discharge of patients in order to make the meagre supply of beds available to someone even more unwell. Well-meaning professionals find themselves in an endless revolving door of threadbare custodial management, desperately holding on to their sense of purpose as carers.

This most recent case necessitates an important process of soul searching for what went wrong in order that we might learn from our mistakes. 25 years ago, I was commissioned to undertake a review of the state of the science of mental health risk assessment  for the Zito Trust, an organisation set up by the mental health campaigner Jayne Zito in the aftermath of her late husband, Jonathan's, death at the hands of a man suffering from paranoid schizophrenia, a case strongly reminiscent of Calocane.

My work in the field of risk assessment then and since has taught me caution about the ability of mental health and criminal justice professionals' to predict behaviour. Mental health practitioners are not only hampered by insubstantial resources; they also face the impossible task of predicting what is essentially unpredictable. The field of risk assessment makes use of the forecasting model. We may consider a person as changeable as the weather, but this is as far as the analogy goes. The weather is predictable, human behaviour is not.

The 'retrospectoscope'

The CQC report states that hospital records show that in July 2020 a psychiatrist noted: "There seems to be no insight or remorse, and the danger is that this will happen again and perhaps Valdo will end up killing someone." Interestingly, despite the intuitive sense that remorse and insight are related to risk, the empirical research finds the reverse to be the case. But more importantly, such observations are only meaningful in hindsight, something often employed by inquiries attempting to understand the problems leading to such tragic an outcome. Using the 'retrospectoscope', in other words, hindsight, they falsely suggest a clear narrative of causation where the outcome could have been foreseen. 

The reality is that when you're a clinician working with mentally ill individuals, and you are looking forward, rather than backward as you would with hindsight, it isn't possible to see this. Risk assessment is a useful tool. But it is always based on looking back at what factors are associated with risk and whether these are present with a particular individual. It is a bit like driving a car with your windscreen blacked out and only the use of your rearview mirror. You wouldn't decline the mirror, because despite not knowing where you're going, at least you know the territory you're in. 

The vast majority of mentally ill people are not violent, in fact the increase in risk compared to the general population is very small. Even previous violence, or the articulation of homicidal intent, rarely mean a person will act upon their thoughts. Models to forecast violence are based on large population studies, which have little predictive validity when it comes to the individual. 

Beyond a toxic culture

As a clinician working with people who suffer mental health problems and show signs of risk, the problems are twofold. In the first place, resources are limited. One has to show that one has gone through the necessary steps to alert services to the concerns one has even though you know the service you're requesting is unlikely to be available. Secondly, violence, particularly serious violence, is an incredibly rare event, even in the presence of all the factors associated with high risk. There are undoubtedly many statements in patient notes saying that a particular individual may end up being violent, whereas there are few cases in which they are in actuality. 

In the past, many a public inquiry has been critical of the care a patient received, including directed at particular clinicians whose careers have been unjustly devastated as a result. This contributes to a harsh atmosphere akin to an inquisition, in which talented practitioners are criticised and younger clinicians with good caring potential remove themselves from working with the people who most need their help. I am always mindful of following clear risk protocols, recording the process in the notes, dotting the i's and crossing the t's so to speak, but ultimately recognising that I do not have a crystal ball, and I am limited in what I can do. 

Humans are primed for narrative; it is our way of making sense of the random data we encounter in our lives. We prefer order over chaos, but this also means that we have a vulnerability to adopt a heuristic that makes intuitive sense but is simply not true, such as the belief that the expression of remorse or insight reduces risk. This is a pitfall of homicide inquiries, which often end in blame and recrimination as a way of avoiding the acceptance of fallibility and the inevitability of tragedy. The potential for criticism inadvertently leads to defensive practice on the part of mental health and criminal justice practitioners, which diminishes rather than enhances the service provided to patients. It leads to a toxic culture in which responsibility is avoided and risk is paradoxically increased. It is thus vital that this latest demand for a review of what went wrong is a true inquiry and not an inquisition.

Dr Stephen Blumenthal is Consultant Clinical Psychologist & Psychoanalyst at the Portman Clinic, Tavistock & Portman NHS Foundation Trust, and Queen Anne Street Practice. He has an interest in understanding risk and has written and published on the subject.