Inferring Causality in Mental Health Homicide Inquiries

Non-statutory independent mental health homicide inquiries routinely make attributions of causality, but it is not clear how they do this. Issues such as poor risk assessment, poor communication between agencies, poor communication with families, poor record-keeping and poor care planning are routinely identified as root causes of mental health homicides. There appears to be an assumption of linear causality, where a cause leads to an effect in a measurable, foreseeable, understandable way; this is held to be symmetrical, in that, it is assumed that the cause-effect relationship will hold if we work backwards as happens in an inquiry. However, is this correct? Dr Deshpande examined this briefly with reference to safety science, emergent causality, and counterfactuals.