Learning from adverse events.

Whenever colleagues meet it seems there is discus sion about the latest inquiry into suicides or homicides. One cannot turn on the television without the news or a documentary referring to the latest tragedy. Risk assessment and defensible documen tation are commonly the subjects of lectures and symposia. Lessons are learned, or not, from published inquiries and associated media attention. The attribution of blame is always high on the agenda. Yet when visiting psychiatric services and talking to staff I am usually impressed by their professionalism and staggered by their workload. It is not surprising that consultants are becoming increasingly upset and angry at the personal criticism and are responding to the reports with pleas about workload, shortage of beds and community resources and deficiencies in the legislation. When reading inquiry reports, or taking part in an inquiry, I cannot help feeling the appropriateness of at least some of the criticisms. It is true that reports ought to acknowledge understaffing, legal inadequacies and so on. Psychiatrists should not be used as scapegoats nor be held respon sible unfairly for the behaviour of others. Equally, we must not be dismissive of valid criticisms. In assessing the care given to a patient, for example, determining risks presented by the patient, it seems to me that psychiatrists emphasise different items from those looked at by an inquiry team. The former look at diagnosis, psychiatric history, forensic history, social history and circumstances, illicit drug use, past suicidal or homicidal thoughts or behav iour and so on, looking for predictors of certain behaviours. The latter looks at the process of the interaction between the patient and the services and of one group of services with another. Inquiry teams are much more likely to be concerned about inconsistencies within patients' records or reports