Articles for tag: change, change management, education, inquiry, investment, lessons, patients, people, risk, safety, standards, waste

The Great Training Robbery: Why Lessons Are Not Learnt

Every NHS trust maintains a mandatory training matrix. Staff are tracked, chased, and occasionally threatened until compliance rates hit the target — typically 85% or above. The annual study day is booked. The e-learning is clicked through. The tick goes in the box. And then, overwhelmingly, nothing changes. This pattern is not unique to the NHS. In 2016, Beer, Finnström and Schrader published a landmark Harvard Business School paper they titled The Great Training Robbery. Their argument was blunt: billions ...

The Southport Inquiry: Analysis (of Phase 1)

On 29 July 2024, Axel Rudakubana carried out a fatal knife attack at a Taylor Swift-themed dance and yoga class in Southport. Three young girls were murdered, and many other children and adults suffered grave physical and psychological harm. The event shocked the country not only because of its brutality, but because it involved a young perpetrator whose history, as later examined by the Inquiry, contained repeated signs of serious and escalating risk. The Southport Inquiry was established because the ...

A Comprehensive Analysis of Mental Health Related Homicides in England (UK)

The Quantitative Landscape of Patient Homicide in the United Kingdom Over the past decade, homicides by individuals in contact with mental health services have posed a persistent challenge for the NHS and the criminal justice system. Data from the National Confidential Inquiry into Suicide and Safety (NCISH) and various independent investigations show a troubling pattern. Patient homicides represent a minority – 11% – of total homicides in the UK. However, they constitute a significant group of incidents where timely service ...

Summary of “Judgments of predictability, preventability and causation of mental health homicides in England 2010–2023”

This article summarises a very long and important study. The opinions presented are not that of the author of this post nor this website. The findings and opinions are paraphrased from the study itself. Inquiry methodology and epistemic constraints The study Judgments of predictability, preventability and causation of mental health homicides in England 2010–2023 [Aug 2025] analyses 162 independent homicide inquiries commissioned by NHS England between 2010 and 2023 following offences committed by individuals receiving mental health care. The authors ...

The 2024 Southport stabbings: A Case of Risk Lacunae and Protective Nets

The 2024 Southport stabbings refers to a heinous attack carried out Axel Rudakubana. He committed three murders and ten attempted murders. This article is constructed largely from information in the public domain and is being updated at intervals, as new information comes to light. Note again our ‘Fat Disclaimer‘. Rudakubana was 17 years old at the time he committed the offences. Axel Rudakubana was convicted of multiple charges related to the 2024 Southport stabbings. He pleaded guilty to: He was ...

The Barrett Inquiry

John Barrett, a 41-year-old man with a history of schizophrenia and violence, was conditionally discharged from a medium secure forensic psychiatric unit in October 2003 following his conviction for a knife attack in 2002. Despite concerns about his compliance with medication and his capacity to recognise signs of relapse, the clinical team supported his discharge, subject to conditions including regular contact with mental health professionals and compliance with medication. In October 2003 John Barrett was conditionally discharged by a mental ...