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.     

Aspects of audit. 4: Acceptability of audit.

Whether or not audit is accepted in Britain will be determined principally by how it is controlled, how much it costs, and how effective it is. The objectives of audit have been defined as education, planning, evaluation, research, and anticipatory diplomacy--that is, starting internal audit before external audit is imposed on the medical profession. Published reports suggest that in Britain internal audit would be more effective andless expensive than the complex professional standards review organisation devised by the Federal Government in the United States.     

Aspects of audit. 5: Looking forward to audit.

Whatever the misgivings of individual doctors, the formal support being given by professional bodies suggests that medical audit will become established in Britain. It is therefore appropriate to heed the advice of pioneers in the field in choosing methods and topics for audit. Practical problems can be anticipated because of the inadequacy of medical records, retrieval systems, and comparable information on practice patterns and evaluation of traditional processes of patient care. The criterion system of audit may provide a common standard for effective review. This can be used for any group of patients with some characteristic in common. It requires good records and a good records staff. Whatever method is adopted, central support should come from the royal colleges, with community physicians and clinical tutors assisting clinicians at the local level.     

The ultimate audit.

The necropsy diagnoses in 78 stillborn and young infants have been compared with the clinical diagnoses in an attempt to justify post-morten examination in this age group. Clinical diagnosis was confirmed in over 88% of cases but unexpected changes in diagnosis were made in six cases, which indicates that selection is of no value.