Analysis of independent inquiries

SANE estimates that many millions of pounds has been spent conducting independent inquiries that reveal the same serial blunders and continuing failures to identify and protect patients let down by the psychiatric system and the public.

Yet this vast sum of money appears to have been squandered, as trusts persist in failing to make basic improvements, such as the sharing of information on the patient’s condition, routine note-keeping, risk assessment and listening to the concerns of families and others.

SANE’s own analysis of many inquiries reveals that as many as one in three of these cases could have been prevented if mental health services responded more rapidly and effectively to the clear warning signs.

Independent inquiries have been set up to examine the “black box” of faults leading to these rare, headline tragedies, but it seems as though in too many cases this vital evidence has gone to waste.

There is a wealth of evidence, conducted by SANE and others, which shows that these inquiries repeatedly reveal the same …

• Errors in services.
• Inability or unwillingness to act.
• Incapacity to hear the cries for help.
• Intransigence in the face of the obvious warning signs that they may be a danger to themselves, or occasionally, to the general public.