The Case of Jason Mitchell: Report of the Independent Panel of Inquiry By L. Blom-Cooper, A. Grounds, P. Guinan, et al. London: Duckworth. 1996. 304 pp. £13.99.

Inquiries After Homicide Edited by J. Peay. London: Duckworth. 1996. 182 pp. £13.99.

Report of the Inquiry into the Treatment and Care of Gilbert Kopernick-Steckel By J. Greenwell, A. Procter & A. Jones. Croydon: Croydon Health Authority. 1997. 45 pp.

Psychiatry has proved a disappointment. It should be medicine for the thinking man, where clinical diagnosis is all there is, not just something to discuss while waiting for the test results. There are big gaps in knowledge, yet clinical pressures force doctors to act, despite knowing that history will show many interventions to have been crude and misguided. The shortage of facts leads to an emphasis on clinical skills. The best formulations encompass a whole life-history, attempting to include the psychological and social alongside the biochemical. Patients may be unreliable informants, so other sources are used, as in any biography. The result is a truly holistic form of medicine.

By contrast with this ideal, much current practice is rather sad. Overwhelming demand has reduced English inner city services to production lines for the treatment of psychosis. Other disorders take a distant second place, or are relegated to the counsellor. The case-loads of some consultants compare unfavourably with those found in the old asylums, hardly leaving time to get to know a patient, much less develop a sophisticated formulation. Patients who hear voices get the injection, those who do not go elsewhere. This is a caricature, but will strike a chord with many community psychiatrists. Hence, the appeal of inquiries when things go wrong. Here is the full history, painstakingly gathered from informants. Old records and notes have been obtained. Nothing is too much trouble. Facts are mulled over. Conflicting statements are reconciled, experts are called in to provide second and third opinions. It is unfortunate that this intellectual energy is brought to bear after a tragedy rather than before, but that should not detract from the fascination of a thorough case study. The description of a patient's care, over a life-time, tells us something about the quality of psychiatric services, that a library of outcome statistics, or league tables could never convey.

These three works cover inquiries into murders committed by psychiatric patients in Britain. By the measure of the previous paragraph, the Jason Mitchell inquiry is one of the best. There are many reasons, including the fact that the panel has five members rather than three, reducing the influence of any idiosyncratic views. The additions are a clinical psychologist with forensic experience and a member of the police force. The panel includes an eminent forensic psychiatrist, yet additional opinions are also sought from other consultants in general and forensic psychiatry. This breadth and depth of expertise is brought to bear on a painstakingly assembled collection of documents and oral evidence. Exploration of the case ranges from the philosophical (why do people do these things?) to the mundane (where do missing records go?).

The nature of the specific case ensures a fascinating report. The killings which prompted the inquiry were bizarre, reflecting the extremes of psychopathology that are rarely encountered, even within special hospitals. The report begins by describing the facts. A 24-year-old patient leaves his hospital ward on a Friday evening in 1994. Although subject to a restriction order following an assault in 1990, he has been conditionally discharged from hospital and is only awaiting suitable accommodation. He is free to leave the ward, but must return within a set time. He does not return that night, and will never return. He travels to the family home, nearby, and stays with his father, going out only twice over the weekend. Police learn later that, on Saturday he tried unsuccessfully to break into a nearby bungalow. At midday on Monday, he tells his father he is returning to the hospital, and leaves. He remains in the area and, during the afternoon, enters the same bungalow unseen, while the 65-year-old owner is washing his car. He hides in the bedroom, emerging after the wife's return home, to confront the elderly couple at knifepoint. They are tied up, placed in separate rooms and strangled. He stays to smoke a cigarette and eat something, takes £25 but leaves more money untouched, then spends the night at a local guest house. The bodies are discovered on Wednesday. Forensic evidence, and witnesses who had seen him loitering, identify the patient as someone the police wish to interview. He spends the next few days in the locality, returning to his father's house on Friday. His father had been interviewed by the police, and had promised to inform them if the patient returned. He did not do so, for unknown reasons. Late on Saturday night, the patient calls his father upstairs to help make the bed. He strangles him with a tie, without warning. Later, he will tell the police of talking to the body, then dismembering it over the next two days (the torso is found on the bed, the head and limbs in sports bags in the loft). Meanwhile, fingerprint evidence has confirmed the patient as a murder suspect. The police visit the father's house again on the following Tuesday. They find it in darkness, with no reply to their knocking, so force their way in to find the patient in the sitting room, looking vacant and disorientated. He tells them he has killed his father, and is arrested.

The following sections of the book begin with an exploration of the patient's psychopathology, moving on to consider his care in both the recent and the distant past. The three chapters considering psychopathology and motivation are particularly good. The patient was not receiving medication when he offended, and the working diagnosis was personality disorder with past episodes of drug-induced psychosis. With hindsight the Inquiry concludes that he suffered from paranoid schizophrenia, which was the diagnosis when he was first placed on a restriction order. It is acknowledged that alternative formulations of this complex case were possible, and there are reminders of the importance of a detailed life-history when diagnosing schizophrenia. Individual mental state examinations, however thorough, were often misleading.

If the diagnosis was problematical, the search for a coherent link between mental disorder and offences proves impossible. Although the Inquiry team had access to interviews with the patient at various times after the event (and after treatment) they obtained a range of different accounts, none of which was satisfactory. Schizophrenia was central to any attempt to understand the offences, but was not sufficient. Personality, relationships and his emotional life must have been relevant, but are poorly understood. As one witness put it: “his psychotic motivation… may be impossible for him to describe rationally (because of its inherent irrationality)”. We often speak of psychiatry's practical limitations, but this conclusion touches on the philosophical boundaries. On some levels, psychiatrists can never understand the object of their study (perhaps this is why many find comfort in biochemical explanations?). Psychological attempts to explain offending in schizophrenia are often crude and superficial. The voices command, the patient obeys like a good soldier. This book shows that such accounts leave the real questions unanswered.

Other chapters deal with the decisions of mental health review tribunals, in-patient treatment, the breakdown of a previous community placement, preparation for discharge and the patient's first episode of psychosis, which occurred when he was in youth custody in 1988. Interesting lessons emerge from each of these areas. For example, missing prison medical records meant that later doctors were unaware of the first psychotic episode, contributing to doubt over the diagnosis.

Overall, this is as good as inquiries can get. It should be read by all psychiatrists. I will deal later with my reservations, some of which relate to cost. For now, I note that the book is 300 pages long, reflecting the thoroughness of the inquiry, and cannot have come cheaply (no figures are given, but I would guess it cost the best part of a million pounds). By contrast, the Report of the Inquiry into the Treatment and Care of Gilbert Kopernick-Steckel fills only 45 pages and one presumes that it cost a lot less. Unfortunately, when the two reports are set side by side one must also conclude that one gets what one pays for, in quality as well as quantity.

In part, the brevity results because the Inquiry centres on the three days between a young man's first presentation to psychiatric services (on a Friday afternoon) to his killing his mother and himself (on Sunday evening). The 33-year-old patient had been assessed as an out-patient at another psychiatric hospital some 13 years before, when he was given a diagnosis of personality disorder. He had not taken up the offer of psychotherapy, and the only other hint of a psychiatric history is a mention of a breakdown he may have had while working in Paris (the report gives no dates, but states that it is not known whether he received treatment at that time). He had recently worked as an architect. The case is, in essence, the first presentation of a psychotic disorder. The report describes a catalogue of mistakes and failures of communication. A consultant arranges a home visit with the general practitioner, but fails to notify the social worker. He then asks his secretary to contact the social worker, rather than speaking to her directly and takes the Section papers away, so that the social worker could only get them by making a long detour. The patient agrees to a voluntary admission, then changes his mind and is allowed to leave as some staff are unaware of a decision that he should be detained. After being returned to the hospital by his family, he absconds while the junior doctor is making arrangements for his detention. There are many other short-comings in his management, and there can be no doubt that the Inquiry provides a useful public service by identifying them. It provides a reasonably detailed account of the three days in question, and a sympathetic view of the family's plight (which had been ignored by an internal inquiry). It is unfortunate that the inquiry team show no curiosity about other aspects of the case. By failing to pursue any explanations, they allow their report to appear both shallow and biased, thereby lessening the impact of the lessons it contains. The most serious problems are superficiality and excessive reliance on the wisdom of hindsight. Little evidence is presented, and much of it is ambiguous. The report quotes the patient's sister, whose reaction on bringing him to the ward was that it was “the most dreadful place I have ever been in”. The comment is taken no further. Was there ambivalence on the part of the relatives about consigning a loved one to such a place? Were staff aware of the relative's distaste for the ward, and therefore less assertive in detaining the patient than they should have been?

The same lack of curiosity afflicts discussion of the clinical issues. What was wrong with the patient? Why did he kill his mother and himself, within a few days of the first sign that anything was amiss? These questions are not even asked but, even with hindsight, the answers are uncertain. The failure to look into these matters leads to two major problems. First, there is no sense of the uncertainty that must have been present in the minds of staff dealing with the case. The patient appeared to be drunk when first seen at home, and when he was first admitted. The doctor who admitted him felt unable to make a proper assessment of his mental state because of the effects of alcohol. The facts as presented suggest that staff should have concluded that something was wrong with the patient, and that there was some risk to others; it is not clear how they could have known what was wrong, or how they could have appreciated the magnitude of the risk. Instead, the Inquiry team rely shamelessly on the wisdom of hindsight, quoting the consultant at the inquest stating that the victim was ‘a sitting duck’. They present no evidence to suggest that the consultant thought the same at the time, and none of his actions suggest that he believed the risk to be so great.

The second problem is, in my view, an unforgivable defect in the report. By failing to ask why the killings happened, they leave open to the reader the conclusion that these events are somehow normal in psychiatric practice. One could come away from reading this report, with the belief that the mentally ill must be watched closely or, given half a chance, they will run off and kill relatives and themselves, simply because they are mentally ill. In fact, this was an exceptional case, with many questions still unanswered. It deserved a more thorough inquiry.

Perhaps this report should serve as a warning about attempts to cap the cost of individual inquiries. The pressure is understandable, with costs of half a million per report being fairly routine, adding up to a massive waste of health service money when one considers the number of reports, and the repetitive nature of the conclusions. The solution, however, must lie in reducing the number of inquiries, rather than doing each one less well if they are to have any value.

Inquiries after Homicide is a collection of papers from a seminar that grew out of the Jason Mitchell Inquiry, and a desire to explore issues beyond the particular case. Like most collections of this type, it is of variable quality, and lacks the passion that the seminar itself generated. One suspects that you had to be there to appreciate the full impact of some contributions. I like Jill Peay's attempt to place inquiries into a legal and social context. She argues that the ‘truth’ reached by an inquiry will be socially constructed, like any other account. There is no reason to assume that a group of experts drawing on their own experience, will arrive at fair conclusions, and the group decision may be more extreme than can be justified by the evidence. A chapter on child abuse inquiries draws out lessons, from 35 such reports, that should have had more impact on homicide inquiries. It is argued that the lawyers who chair inquiry panels are skilled in reconstructing incidents in terms of individual actions, at the cost of an understanding of the context of events, and the interactions between individuals. This limits the lessons that can be learned, while the inquiry process compounds professionals' inevitable feelings of responsibility and guilt, with a consequent negative impact on the service. They conclude that inquiries had a constructive effect on child protection work, but this was outweighed by their social, professional and personal costs. It is disappointing to see that the health service is headed down this road, with so little account taken of these well-documented problems. The description of fear leading to slavish adherence to the letter of bureaucratic policies, rather than to the development of a better service, is a concern that many psychiatrists will echo.

I found this book most interesting when it stepped outside the narrow world of inquiries. Rock's chapter deals with the relatives of homicide victims (the secondary victims), providing a glimpse of the horror of losing a family member in this way. The most compelling argument for the continuation of statutory inquiries is that they assist the bereaved family, by letting them know what really happened, and by giving some assurance that efforts will be made to prevent the same thing happening to someone else. This is a powerful argument, but applies equally to all the cases described by Rock. One must welcome any move to improve the treatment of victims, but there is no argument for creating two classes based on whether or not the offender was a psychiatric patient. Why do the relatives of those killed by the intoxicated or by the racist not deserve an inquiry? Also, given the enormity of the loss, it is doubtful that any inquiry could satisfy the bereaved. In a moving annexe to the Mitchell report, the relatives express their feelings and make it clear that they are far from satisfied, even by such an extensive investigation of the case.

The Mitchell killings happened over four years ago. Inquiry reports keep on coming, and political pressures are likely to ensure that they continue for the foreseeable future. Psychiatrists must accept some responsibility for this situation. The profession was slow to recognise the statistical association between schizophrenia and violence, and has still not adopted violent behaviour as a routine outcome measure. Community psychiatrists have sometimes been too quick to take on the psychiatric care of a whole sector, while avoiding questions about the standard of care that can be expected by an individual patient, as one of a case-load of 300. We should be addressing these matters urgently, and taking back the initiative in dealing with a legitimate public concern. The alternative, an endless series of inquiries and new bureaucracies forced on an unwilling profession, would be unbearable. It would also represent a terrible waste of resources. Governments are fond of telling us that health problems cannot be solved by throwing money at them, and it seems unlikely that this one will be solved by throwing money at lawyers.