Causation,historiographic approaches and the investigation of serious adverse incidents in mental health settings

Abstract

To improve the safety of healthcare systems, it is necessary to understand harm-related events that occur in these systems. In mental health services, particular attention is paid to harm arising from the actions of patients against themselves or others. The primary intention of examining these adverse events is to inform changes to care provision so as to reduce the likelihood of the recurrence of such events. The predominant approach to investigating adverse incidents has relied on the cause-and-effect conceptualisation of past events. Whilst the merits of approaches which are reliant on cause-and-effect narratives have been questioned, alternatives models to explain adverse incidents in health settings have not been theoretically or empirically tested. This novel article (i) examines the notion of causation (and the related notion of omission) in the context of explaining adverse events in mental health settings, and (ii) draws on a long-established discipline devoted to the study of how the past is interpreted (namely historiography) to theoretically investigate the innovative application of two historiographical approaches (i.e. counterfactual analysis and historical materialism) to understanding adverse events in mental health settings.

Keywords

causation cause and effect counterfactual historical materialism historiography omission serious incident

Introduction

Approaches to improve safety in mental health care systems rely upon investigating the causes of adverse incidents associated with serious harm, such as suicides or homicides involving patients (NHS England, 2015). Typically, the chosen methodology has been root cause analysis, but more recently its effectiveness in preventing recurrence and improving patient safety has been questioned (Martin-Delgado et al., 2020; Wu et al., 2008), whilst concerns remain surrounding associated intrinsic cognitive biases and an oversimplification of causation (Gyekye, 2010; Neal et al., 2004; Vincent, 2003). Such conventional approaches evaluate the causal relevance of factors through a cause-and-effect model resulting in a reductionist time-bound cause-effect sequence that is liable to strip complexity from the resulting explanation (Neal et al., 2004; Vincent, 2003). Despite the increasing recognition of the limitations of this model in deriving a thorough understanding of adverse incidents, and some exploration of alternative models (Hagley et al., 2019), as yet the applicability of models to understanding adverse incidents in healthcare settings that do not rely on the idea of cause and effect have not been investigated. As the evolving NHS patient safety strategy will continue to rely upon incident investigations (NHS England and NHS Improvement, 2021) a turn towards historiography, a discipline whose sole concern is to consider how to interpret the past (Buchanan, 2018), is likely to be fertile in offering alternative models of understanding notable events that have already occurred. The authors are not aware of any previous exploration of the relevance of historiographic methods for understanding adverse events in mental health settings, and, in this paper they (i) examine the notion of cause in deriving understanding of a such serious incidents, and (ii) test the theoretical application of key historiographic methods to illuminate their utility and explanatory power as novel approaches to understanding adverse incidents in these settings.

Cause in the context of serious mental health incidents

A cause can be generally understood to be an event that is necessary and sufficient for a subsequent event to occur, more specifically referring to the free decision to act of a conscious agent (e.g. a boy’s decision, the cause, to kick the football which caused the window to break), or a relationship of conjunction or correlation between events irrespective of any conscious agent (the rain caused the ground to become wet) that may be amenable to intervention (Collingwood, 1938). This latter sense draws on a linguistic laissez-faire animism that stems from the tendency towards imbuing the inanimate world with sentience (Collingwood, 1938). In both instances, given the predicament captured by John Stuart Mill’s conclusion that an objective identification of causes requires an impossible ideal of a ‘bad infinity’ of all acts and omissions (Rigby, 1995), the recognition of a cause must be subjective and socially determined. This is because objectively an event has a multiplicity of causes and necessary conditions (the boy’s kick of the football would not have broken the window if not for the causal prerequisites of the windowpane’s brittleness, window’s placement, wind direction or speed and so on), as well as each cause in turn requiring its own cause, forming an infinite regression of explanations instantaneously becoming explananda ending at the Big Bang (Fischer, 1992; Rigby, 1995). An objective causal understanding sees all causes as equal because it has no inherent rationale for prioritising certain events as causes (Rigby, 1995); therefore, the identification of a cause, with simultaneous relegation of other events to the status of causal factors or conditions, necessitates a subjective selection motivated by the socially determined purposes or a priori assumptions behind understanding an event’s causes (Collingwood, 1938; Froeyman, 2009; Rigby, 1995).

The facts of history ‘cannot exist in the pure form: they are always refracted through the mind of the recorder’ (Carr, 1961), and in this fashion incident investigations determine certain factors to be causes, with this determination being motivated by the potential relevance of the factor in generating recommendations for adjustments to service provision that could prevent recurrence (NHS England, 2015). Conventional investigation methods cannot expect to achieve an objective causal understanding of an incident, but can draw attention and reveal inadequacies in interrelated clinical and managerial areas (Neal et al., 2004; Vincent, 2003). The causes selected are acts belonging to professionals because they are considered more preventable or controllable suggesting, in line with the causal interventionist stance, that they can be eliminated through improvements in service provision, whilst the infinitude of causally relevant events that are not perceived to be amenable to change are ignored (Collingwood, 1938). Such acts are liable to be viewed as more causally relevant if they occur in closer proximity to the incident itself (Collingwood, 1938) or if they differ from an expected standard of practice (Froeyman, 2009). The preference for recognising the acts of individuals as causes demonstrates how institutions, in ordering such investigations, embody Weberian bureaucracies, in which problems are solved through regulating the practice of individuals, who are moulded towards the obligations of clearly defined roles (Martela, 2019). Take, for instance, the act of administering a medication at a dose well above the safe limit. Through understanding the causes of the act, recommendations can be made for changes in practice that would reduce the likelihood of its recurrence, such as causal factors related to the doctor’s training, their familiarity within the area of practice, or the circumstances under which they were practising. Whilst scenarios may arise in mental health settings where a practitioner’s act can directly cause harm, there are also incidents where linking the practitioner’s actions and harm is not straightforward. Consider the following scenario:

Andrew was a 30 year old man with a diagnosis of borderline personality disorder. He presented to A&E with suicidal ideation consisting of recurrent thoughts of hanging himself. He had not made an attempt to harm himself or end his life. He was referred to the liaison psychiatry team. After assessment, the liaison psychiatrist found Andrew to be of low risk for self-harm or suicide. On this basis the psychiatrist felt Andrew did not require admission to hospital and that he should be discharged home, with community follow up, to his supportive partner. He was found dead after ending his life the following week. A serious incident investigation was called to examine the cause of Andrew’s suicide. The investigation found the psychiatrist’s decision not to admit Andrew to hospital to be a root cause of the adverse incident.

The investigation team, motivated to find controllable factors to prevent future incident recurrence, determines the psychiatrist’s decision, to be the cause of the incident. However, if cause is understood as the decision of a conscious agent to act, then the cause rests in Andrew’s mind as his decision to end his life by suicide, and is understood using explanatory connecting mechanisms between processes in his mind and acts (including of suicide) (Nathan and Wilson, 2020). This understanding can be elusive, most obviously in the case of a patient suicide, and, even when those involved are available, the subjective account can be unreliable or self-serving (Fischer, 1992). Like all practitioners involved with patients who go on to carry out acts with serious adverse consequences, the liaison psychiatrist could conceivably influence the subjective processes in Andrew’s mind in a way that has a bearing on his subsequent suicide, but it is less clear exactly how this constitutes a cause that was necessary or sufficient for his suicide act. This understanding is further obscured because the purported causal connection between the psychiatrist and patient’s suicide is not an act; rather it is an omission.

Omissions

The investigation in the scenario found the cause of the suicide to be the psychiatrist’s decision not to admit Andrew to hospital, which represents an omission, defined as a failure to act (Fischer, 1992). Due to the lack of real events leading from an omission to the event, proving an omission to be causal can require elaborate hypothesising (Fischer, 1992). McGrath (2005) used to the following scenario to examine the relationship between cause and omission:

Alice is going on holiday and Barry promises to water her plant while she is away. Barry does not water the plant which subsequently dries up and dies. Barry’s omission of not watering the plant is the cause of its death.

In this instance, the reality of Barry’s failure to water the plant prior to its death is compared against a counterfactual scenario, in which Barry waters the plant preventing its death, and consequently Barry’s omission is duly implicated as causal. However, other counterfactuals exist that counter this: a second individual could have watered the plant, or the neighbour dislikes the plant and would have doused it with acid after Barry watered it. Notwithstanding the byzantine reasoning involved in hypothesising how the introduction of omitted acts would have affected the course of events, it is apparent that finding an omission to be causal through using counterfactuals can always be countered through the conjuring of alternative counterfactual scenarios in which the omission is not causal (McGrath, 2005).

Identifying omissions as causal based on their proximity to an event is likewise vulnerable to alternative counterfactual reasoning. For instance, even if Barry’s omitted act was the most proximate would-be preventer of Alice’s plant dying, it could equally be true that Alice’s neighbours saw the plant wilting without watering it or Alice’s best friend also promised that she would water the plant but did not. Furthermore, it is not necessarily true that proximity to an event determines whether an omission is causal, for example, if earlier in the day Alice’s neighbour did not move the plant inside amidst strong winds and it toppled over, then Barry’s later more proximate failure to water the plant is causally irrelevant to the plant dying (McGrath, 2005).

Many may agree that, based on a reasonable expectation that Barry should keep his promise of watering the plant, Barry’s omission is the cause of Alice’s plant dying, leading to the conclusion that ‘an omission causes an event, if when an omission occurs the event occurs, and the omitted act is a normal would-be preventer of the event’ (McGrath, 2005). This stance is underpinned by the ceteris paribus assumption, in which the most contingent cause is selected from other factors constituting the normal course of events, but applied to comparing a normative counterfactual scenario to actual unexpected events (Gerring, 2005). However, this approach can still be countered through counterfactual reasoning involving alternative expectations; for instance, Barry is an inveterate liar and cannot be expected to keep his promises, Barry was certain in his belief that it was going to rain, or Barry believed Alice’s neighbour would water the plant.

In clinical practice acts and omissions may be evaluated against clinical standards, comparable to using reasonable expectations; if an incident is prevented by an act, and it is normally expected that in the given circumstances a professional would carry out this act, then the omission of this act could be seen as a cause were the incident to occur (Fischer, 1992; McGrath, 2005). Nevertheless, in the context of incidents, the omission can only be definitively understood as a cause through knowledge of the subjective state of mind of the professional alongside the exact circumstances at the time in order to appreciate if a deviation from the expected standard was controllable or justified (McGrath, 2005); after all ‘history cannot be written unless the historian can achieve some kind of contact with the mind of those about whom he is writing’ (Carr, 1961). Even with this understanding, alleging an omission as causal does not implicate the professional as guilty of misfeasance or nonfeasance (Fischer, 1992), especially within psychiatry, because the omissions of the practitioner are often steps removed from and tortuously (through previously explored counterfactual reasoning) linked to the ensuing untoward act, which itself remains firmly connected to the patient’s mind.

Historiographic approaches

Simple cause-effect sequence

Current investigation approaches understand incidents through a cause-effect sequence, comprised of a chain of chronological events that reach their denouement at the serious incident, that extends meaning to those events identified as causal and also amenable to change. The consequent inherent preference is towards recognising the acts of professionals, believed to be controllable, as causes, rather than causal relationships of constant conjunction which are not. For example, it would be pointless for the investigation to conclude that the cause of Andrew’s suicide by hanging was the gravitational force of the Earth, as this would have no implications for adjustments to service provision that could improve patient safety. However, without an understanding of the subjective states of mind involved in the incident, it can be difficult to find acts or omissions belonging to professionals as causal, because explaining past behaviour involves supplying the psychological states of the agent (Erkkilä, 2015). Given that the psychiatrist interacts with Andrew before his suicide act, his assessment of the risk may have been fair at that particular time; the psychiatrist only has limited evidence to judge all future states of consciousness and whether these are linked to untoward acts, whilst also appropriately weighting the probability that no untoward act occurs (Nathan et al., 2021). The same consideration would have to be given to the patient’s decision to commit an untoward act, as their choice was made from many alternatives, dependent upon their state of mind in relation to their immediate goals, perception of available choices and intuitive probabilities assigned to each (Zimmerman, 1989).

More fundamentally, the cause-effect sequence stems from applying the rationale of the natural sciences, particularly classical mechanics, to our understanding of causation; it contains a belief that ‘once all the facts are discovered they will fall into a chain of events linked in mechanical fashion by a relationship of transitive causality’ (Jones, 1976). However, this positivist approach imposes severe limitations, because placing events in a correct temporal sequence does not necessarily mean the preceding event caused the subsequent, known as the post hoc ergo propter hoc fallacy, as well the fact that the sequence struggles to represent the reality of a complex multiplicity of causes (Jones, 1976; Tosh, 2002) or account for random or non-stationary processes (Zimmerman, 1989). As a result, the approach provides less causes, while these causes are not likely to be the most important, just those associated with the sequence of day-to-day events, rather than longer term or wider structural factors (Tosh, 2002). Historians, concerned with understanding the cause of unique events, use alternative frameworks of interpretation to achieve contact with the minds and motives of agents (Carr, 1961; Tosh, 2002), both as individuals and as a collective, whilst also being able to comprehend changing social relations that are too complex for positivistic understanding (Hobsbawm, 1968; Jones, 1976). From a range of historiographic approaches, we have considered two methods, Weberian historiography and historical materialism, that examine cause differently and may have relevance for serious mental health incident investigations.

Weberian historiography

‘Historians do not assume events are inevitable before they have taken place, frequently discussing alternative courses that were available to agents on the assumption that the options were open, and then explaining why one course was eventually realised rather than the others’ (Carr, 1961). In this fashion, Weberian historiography employs both comparative and counterfactual analysis to evaluate differentiating factors, or potential causes, within selected dimensions (Froeyman, 2009; Rigby, 1995). According to Weber, ‘historians cannot avoid reasoning, counterfactually, about historical events that did not occur, in order to identify the significant causes of what did occur’, and ‘we cannot assess the causal significance of a possible cause without trying to imagine what would have ensued in its absence’, whilst he advocated using counterfactuals to deduce ‘the degree to which a particular cause favoured a given effect’. Therefore, counterfactual methodology seems particularly relevant since it has been used as a ‘debiasing tool’ for the retrospective application of an explanation for an event (Tetlock and Belkin, 1996).

Such counterfactual approaches may be useful to derive putative causal hypotheses for the incident under investigation, whilst allowing some testing of the applicability of the hypothesised explanation for the outcome, that is, the index incident (or consequent). The relevance of potential causal factors (e.g. hopelessness, alcohol intoxication, relationship breakdown, availability of means) can be individually ‘tested’ within a subjective conditional in which the factor (or antecedent) is absent. However, investigations are also (if not primarily) concerned with the clinical decisions that were made prior to the incident. The standard historiographic counterfactual approach – counterfactually altering an antecedent of interest – has less utility for analysing the causal relationship between a clinical decision and the incident. This is not only because a clinical decision not to act in a way that may be hypothesised to have prevented the outcome is not, as already shown, necessarily a cause. Additionally, when a serious incident, such as suicide, has occurred, and the factual immediate antecedent decision was not to admit then a retrospective analysis would tend to start from the position of favouring the counterfactual antecedent (i.e. to admit). It may be difficult to dispel the influence of this bias from an analysis of the case and to remain mindful of all the factors that the clinician may have been balancing at the time (e.g. including stress, isolation from usual support, use of a scarce resource). Further, the learning from such an evaluation would have limited applicability since it relies on a hypothetical but invalid scenario in which it is known that the person is going to kill themselves. There is an alternative counterfactual approach, though, that allows an exploration of possible causal factors in a way that is likely to reduce bias. JS Mill’s ‘method of difference’, similar to the rationale underpinning the randomised controlled trial, states:

If an instance in which the phenomenon under investigation occurs, and an instance in which it does not occur, have every circumstance save one in common, that one occurring only in the former; the circumstance in which alone the two instances differ, is the effect, or cause, or an indispensable part of the cause, of the phenomenon.

Thus, in the alternative counterfactual approach, the clinical decision can be evaluated in a subjunctive conditional in which the consequent (rather than the antecedent) is imagined to be false (i.e. suicide did not occur) instead of evaluating their actions in light of the retrospective knowledge of the factual scenario (suicide occurred). Adopting this approach deals with a fundamental cause of retrospective bias which is that what may appear to an investigator be a potential explanatory antecedent for a known past incident, appears from the clinician’s perspective to be a potential risk factor for an unlikely future event. The alternative consequent counterfactual methodology also addresses another potential problem with the standard approach. If a decision is deemed appropriate when there is not a negative outcome but inappropriate when there is a negative outcome, this would mean the assessor who does not know the outcome can never know contemporaneously whether their planned decision is appropriate or will be judged as such. Finally, an alternative consequent counterfactual position encourages the investigator to adopt the perspective of the assessing clinician, which is essential in informing learning from the investigation, since the learning should be applicable to the clinician who does not know the outcome. This approach would require a different test of the appropriateness of the decision (e.g. whether it is in line with the guidelines for the management of mental disorder and reducing risk). A potential benefit of such a test would be that a clear distinction could be made between an evaluation of (i) whether the assessor followed the guidelines appropriately, and (ii) whether the guidelines are appropriate. Therefore, evaluating the clinician’s approach to risk assessment and clinical decision-making in the counterfactual scenario that the person did not kill themselves is likely to have more applicability to practice without reducing the rigour of the investigation.

Historical materialism

It appeared to Engels that the concept of cause and effect is so bound to the individual case that in the process of generalising from that case it loses its wider explanatory utility (Engels, 2001) because, even if events appear to occur twice, they do so under different sets of conditions which must be treated from different points of view (Groopman, 1982). Historical materialism, on the other hand, looks for the ‘ultimate cause and great moving power of all important historic events in the economic development of society’, through examining the modes of production, group division into classes and the consequent struggles motivated by competing interests (Engels, 2001; Jossa, 2018). Because the ideas of the approach have wider explanatory utility, historical materialism offers an effective framework for understanding complex events (Groopman, 1982; Hobsbawm, 1968). However, the authors are unaware of its application to the process of understanding the cause of serious incidents, in which it encourages a shift in focus from the level of individual case-based decisions to the wider system within which such decisions are made.

In his first and most comprehensive statement of historical materialism, also known as Marxist historiography, Karl Marx said individuals must meet their needs through harnessing productive forces over the modes of production, which are dependent on the material conditions (Marx and Engels, 2011). As needs increase, the productive forces must be used more efficiently, principally through increasing development of the relations of production, referring to the co-operation and division or specialisation of labour between individuals (Marx and Engels, 2011), leading to class formation. Various classes compete with each other to use the scarce productive forces to meet their needs, resulting in class struggle, creating tension (Marx and Engels, 2011). This tension is mediated by the superstructure that rests on the base (combined productive forces and relations) (Marx and Engels, 2011), which together form a system. The superstructure (composed of laws, institutions, ideologies and so on) reflects the expression of the class that controls the productive forces, whilst also influencing the conditions under which the productive forces are applied under, and therefore each class’s existence, including ideas about their own position (Marx and Engels, 2011). Through insisting on a system composed of a hierarchy of levels that are confronted with tensions or contradictions (arising from the relations between individuals and groups, both within the system and outside environment), historical materialism offers a structural and functional framework to gain causal understanding for events (Hobsbawm, 1968).

Marx’s illuminating application of his historiography to real historical events in ‘the Eighteenth Brumaire of Louis Bonaparte’ (1852) (Groopman, 1982; Hobsbawm, 1968) had an exceptional influence on the writing of history (Tosh, 2002). In analysing the coup d’état of Louis Napoleon, nephew of his famous namesake Napoleon I, and studying the relations between the French bourgeoisie and proletariat, groups defined by their position with respect to the modes of production, Marx unveiled his materialist conception of history:

‘Men make their own history and everywhere they are in chains to their past: men make their own history, but they do not make it just as they please; they do not make it under circumstances chosen by themselves, but under circumstances directly encountered, given and transmitted from the past. The tradition of all the dead generations weighs like a nightmare on the brain of the living’. (Groopman, 1982)

He adroitly used a multi-class model to analyse the myriad patterns of different class struggles to derive causal understanding of an event in terms of human agency and relations, political events and structural conditions (So and Suwarsono, 1990), demonstrating ‘how the historical materialist approach sheds light on the structural causes as the long-term factors which render events inevitable, whilst also defining the limits within which the actions of individuals or classes have their scope’ (Tosh, 2002). Class analysis, itself more generally an interpretive scheme to make sense of events (So and Suwarsono, 1990), considers how differing class interests lead to tensions, and has relevance because actions and motivations within a collective have greater impact than those of the individual, whilst being understandable and more predictable (Tosh, 2002). Within the mental health care system, appreciating how such tensions are the principal determinants of change (Tosh, 2002) could have implications for understanding the causes of serious incidents. Consider the following expanded scenario:

Andrew was a 30 year old man with a diagnosis of borderline personality disorder. He presented to A&E with suicidal ideation consisting of recurrent thoughts of hanging himself. He had not made an attempt to harm himself or end his life. However, Andrew believed that he could not keep himself safe at home and should be admitted to hospital. He was referred to the liaison psychiatry team. After assessment, the liaison psychiatrist found Andrew to be of low risk of suicide. Despite Andrew struggling with intrusive thoughts of suicide he had made no plans or steps towards harming himself. Andrew readily identified protective factors, including his wife, parents and pet dog. Andrew also agreed that he would contact services if his mental state deteriorated. Having balanced Andrew’s autonomy, the potential iatrogenic effects of admission, the pressure on resources and the safety of the patient, the psychiatrist concluded that Andrew was not a priority for admission to hospital and consequently he could be discharged home, with community follow up, to his supportive partner. He was found dead after ending his life the following week. A serious incident investigation was called to examine what caused Andrew’s suicide. The incident found the psychiatrist’s decision not to admit Andrew to hospital to be a root cause of the adverse incident.

When applying an explanatory framework based on historical materialism, the interests of individuals must be discerned and ‘classes’ formed around shared interests; however, in reality individuals have many interests held to different degrees, meaning any such grouping would never be uniform. Despite this, relevant individual factors (for instance, the degree of control held over decisions to admit a patient to hospital, but not the football team supported by the person) can form the basis for the collation of individuals into classes and subsequent class analysis. In the scenario, Andrew attempts to meet his need to guarantee his own safety from suicide through seeking use of the productive forces, represented by an inpatient hospital admission, which are in turn underpinned by the economically scarce material reality of limited available inpatients beds, staffing levels, funding and so on. The relations of productions can be grouped into classes, the patients (Andrew) and the professionals (the psychiatrist), with respect to their shared interests and position relative to the productive forces (So and Suwarsono, 1990; Tosh, 2002). Accepting that ‘the history of all hitherto existing society is the history of class struggles’ (Marx and Engels, 2002), and consequently considering the class interests at play, a novel understanding of Andrew’s suicide can be derived. The patients want to use the productive forces, the inpatient hospital admission; however, the professionals control and want to allocate the inpatient hospital admissions. The material constraints limit the available number of inpatient admissions; hence professionals must decide, based upon their clinical judgement and admission criteria, which patients warrant admission. The mental health care system comprises the base (the relations of production, patients and professionals and productive forces, for instance inpatient hospital admissions) and the chimeric superstructure, which reflects the ideology of maximising patient safety, expressed in the prevailing mental health advice for the public, the serious incident investigation process that aims to recommend adjustments to service provision and so on.

Considering the class interests at play it is evident that patients, faced with scarce inpatient admissions, are incentivised to influence the decision of professionals in favour of admission, whilst also having to compete with other patients for scarce beds. Within the mental health care system, patients are advised to seek help when they cannot keep themselves safe, but the idea that the decisions of professionals, such as choosing not to admit a patient to hospital, are the cause of serious incidents and do not maximise patient safety is reinforced by conventional investigation findings. However, professionals, faced with material constraints, want to allocate inpatient admissions effectively and must refuse some patients for admission. Executing this interest directly relates to their ability to keep their position that represents their own means of subsistence, and in which they are replaceable and commoditised (Marx and Engels, 2002). When deciding against an admission, a tension or contradiction arises between patients’ and professionals’ interests. This tension is normally mediated by institutional faith in professionals’ decisions, provided they meet the expected clinical standard, whether or not to admit patients in view of scarce available inpatient admissions, thus holding the system in a fluctuating approximation of equilibria.

Serious incidents that arise within this system could be understood through considering the tensions arising between the different groups, which bear resemblance to the class struggles articulated within historical materialism. In the scenario, tension arises between Andrew and the liaison psychiatrist when Andrew is declined discharge in favour of community support. The mental health care system normally mediates this tension through the institutional faith in the liaison psychiatrist’s decision, provided his assessment met the expected standard and therefore, provided his assessment was stellar, the liaison psychiatrist’s actions or omissions cannot be held as causal in Andrew’s suicide. However, whether or not the expected standard itself was appropriate can be examined. Furthermore, because the institutional ideology necessarily arises from the underlying material conditions, in this instance the scarcity of inpatient beds, it becomes apparent that another structural cause of Andrew’s suicide is the limited number of available inpatient beds. Finding the psychiatrist’s acts or and omissions to be causal, especially if they met the expected standard, would neglect the more widely influential force of the standard itself as well as the constrained resources, and consequently offer little reassurance for effective recommendations that could prevent incident recurrence and improve patient safety. Even if the expected standard was not met, then, as previously explored, the minds of both the psychiatrist and patient must still be understood in relation to their acts and omissions before a causal understanding could be achieved.

The utility of this model can be extended to explore the potential effects of the serious adverse incident and its investigation. They may present a potentially destabilising force for the mental health care system which subsequently could face greater, disruptive tensions. This is because conventional investigation approaches, through identifying the actions of professionals as causal without appreciating the tensions arising from the material reality, create and embed a consequent risk aversion when assessing patients; professionals become increasingly wary of the existential career threat, chiefly a loss of their livelihood, that could arise if they decide against admitting an individual who then goes on to be involved in an untoward incident. Patients themselves are further incentivised to push for admission to ensure that professionals, viewed as reluctant to admit them, do not deny them the chance to guarantee their safety. Thus, individuals in both classes, motivated by their interests, now develop a default predilection towards admissions; however, the scarcity of inpatient beds still exists, and a continued misallocation of resources develops, resulting in worse outcomes for the entire collective. Investigations that continue to find the acts and omissions of professionals as causal would only further the disequilibria within the system, without improving patient safety because the material resources are used increasingly ineffectively, for example leading to bed shortages so patients, truly needing inpatient care, cannot be readily offered an admission. Conceivably, this increasingly untenable state would reach an inflection point, at which point the mental health care system would strive towards stabilisation through (i) further rationalising the assessment of patients, while promoting institutional support for avoiding unnecessary admissions as well as the decisions of professionals (provided an ever-refined expected standard is met and, if not, the decision first explored in relation to the states of mind involved), and (ii) developing the productive forces (for instance increasing the number of inpatient hospital admission beds) involved in delivering effective mental health care and ultimately improving patient safety whilst at the same time reinforcing a dependence on admission as a safety solution.

Conclusion

In conclusion, the current approach used to investigate serious mental health incidents is limited because it understands the cause of events in a simple cause-effect sequence. As a result, there is a bias towards seeing the actions of professionals as causes, but this can be problematic in mental health incidents, where it is often less clear how the acts or omissions of professionals could affect subjective processes in a patient’s mind before deciding to commit an untoward act. Furthermore, because in reality there is a complex multiplicity of causes, the current approach may identify less causes overall, while missing more significant structural factors. Being able to appreciate other causes, especially those that are potentially more important, could lead to more effective adjustments in service provision and improvements in patient safety. As demonstrated in this novel analysis, alternative approaches towards understanding the causes of complex events can be found in historiography, including counterfactual approaches and historical materialism. Through applying these approaches to a theoretical scenario it is clear that they may have explanatory utility, as part of arsenal of approaches towards understanding causation, for investigations seeking to understand the causes of serious mental health incidents.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Rajan Nathan

Author biographies

Sahil Bhandari (MBChB, BSc) is a Psychiatry Core Trainee within the North West School of Psychiatry, UK. He currently works within a Forensic Psychiatry service. His research interests are driven by a desire to understand the subjective human experience through exploring both the nature of and relationship between phenomenology and our actions in the world.

Øyvind Thomassen is professor, Dr. Art., in history (history of science and technology) at Norwegian University of Science and Technology, Dept. for Modern History and Society and St.Olav Hospital, Forensic department Bröset, Centre for Research and Education in Forensic Psychiatry. His current research includes a focus on forensic and security psychiatric history.

Rajan Nathan (MB, BCh, MRCPsych, MMedSc, DipFSc, MD) has worked as a Consultant Forensic Psychiatrist within the NHS for over 20 years, and he is currently also Director of Research in Cheshire and Wirral Partnership NHS Foundation Trust, Honorary Senior Research Fellow at the University of Liverpool, Visiting Professor to the University of Chester, Adjunct Professor at Liverpool John Moores University, and North West Coast NIHR Mental Health Research Lead. His research interests are understanding risk, process-level understanding of violence, subjectivity and psychopathology and clinical decision-making.

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