Root cause analysis

We all look forward to Homicide Inquiries, mandated by the Department of Health Circular HSG(94)27 (Department of Health, 1994) being replaced or modernised as soon as possible, since there seems to be very little evidence that the enormous costs of these inquiries are justified by the benefits. Root cause analysis, as described by Neal et al (Psychiatric Bulletin, March 2004, 28, 75-77), may offer useful alternatives. However, reading their article left me with two doubts, both of which relate to the notion of ‘logical relationships’ between different ideas or issues. It is important that logical decisions are taken in medical practice, since this is one of the legal tests of good-enough medical practice. However, I would raise two concerns; first not everybody would agree on what constitutes a ‘logical relationship’. For example Neal et al suggest in their first figure that there is a ‘logical relationship’ between failure to diagnose and treat an emerging psychotic illness and suicide. However, to make such a statement is already to have completed the point of the inquiry without establishing that there is a logical relationship. Furthermore, it could be argued that the whole point of an inquiry is to establish whether there is a relationship or not between two events, and to bear in mind the possibility that there are lots of different types of relationships between events, including the possibility of no relationship.

The other aspect that is sometimes left out of ‘logic’ is the application and understanding of strong feelings. We sometimes make decisions (which in retrospect seem illogical) because we are moved by powerful feelings, usually negative ones of fear, anxiety and hostility. Post-incident inquiries frequently meet and are moved by similar feelings, and those feelings affect the way that they perceive logical relationships and analyse them. Although it seems that root cause analysis might provide a more systematic way of looking at the evidence that comes before inquiries, I am not convinced from Neal's article that they will deal with these other aspects.