Qualitative study of district health board inquiries into mental health related homicide in a New Zealand sample

The aim of this study is to identify the methods and content of hospital-based serious incident reviews involving mental health related homicide where a service user was the perpetrator between 2007 and 2017. Eleven reports were obtained from mental health services in New Zealand's largest city and thematically analysed. Nine used the London protocol to identify clinical and system factors that may have contributed to the serious incident, but there was considerable variation in the way in which it was applied. Feedback to services was inconsistent. The voices of family members of the victims were largely absent and consideration of cultural context was missing. A structured protocol to specifically address the mental health context in New Zealand and internationally could resolve some of these issues and lead to a process that is more likely to provide comprehensive coverage of relevant matters and produce clear recommendations to effect improvements to services.