The phenomenon of patient homicides committed by health service employees has, in the previous years, repeatedly aroused much attention. The cases made known in Germany, the USA, Holland, Norway, and Austria appear to provide evidence to the effect that we are not only dealing with unique incidents. The scientific investigation of this especially sensitive taboo-topic is, to date, missing. The judicial trials carried out emphatically indicate that culprit motives, colleague behavior, but also to a large extent decisions made by superiors remain unclear. It remains controversial, what effect working conditions, strain of employees, their level of education and personal viewpoints over such criminal acts they possess. Finally, the long latency period between the first internal suspicions and the responsible parties' appropriate reactions requires duplicatable explanation. The following paper presents a German single-case study of patient homicide by a female nurse. The focus on causality rests on the presentation of developments up to the point where the long-fermenting suspicion could no longer be dismissed, and appropriate consequences took place. The account largely avoids the "definite" findings required during the judicial process. It concerns rather above all an open, uncertain, and possibly without external influence course of development which in stages each colleague in the health professions can trace, to the point where the uncertain and horrifying suspicion became a certainty. With this single-case study in hand it is made understandable in which ways personal circumstances and professional conditions at the worksituation can intertwine in such a way that the original motivation to help turns into its abysmal opposite. It is the author's intention to make preventive learning possible through this single case study. Every employee in the health professions should proceed on the assumption that such occurrences could also in his own field of work come to pass. In this respect, it is of considerable importance to differentiate between hasty and untenable incriminations and original increasing early-warning signs.
Psychiatry and criminal justice have been closely related for a long time. Traces of such ties can already be found during the 19th century through the establishment of the contemporary systems of social control. Various questions that will mark the development of policies in this domain were important objects of discussion and analysis: Is mental illness a cause of criminality? Should the "insane" be held responsible for their crimes? What are the appropriate measures to heal, reform, control? In other words, should we consider the individual as sick or as criminal? If these questions are formulated differently nowadays they haven't lost any of their relevance. In this article, we will briefly present the forms of intervention available to the criminal justice system when dealing with persons suffering from mental health problems. This presentation is based on recent studies conducted in Montreal, elsewhere in Canada, as well as in the United States. The main stages of the criminal justice process will be examined, taking into account the recent modifications to the Canadian Criminal Code and its impact on the relations between the courts and psychiatric facilities. This type of situation is not without impact on community mental health for two main reasons. First, with the diminishing public funding of various health services there seems to be a growing practice of criminalization of persons suffering from mental health problems, especially the most vulnerable segments of this population. Secondly, there is a growing trend, in the criminal justice system, of requiring support from community groups or facilities to deal with these criminalized individuals. In the coming years criminalization will constitute an increasing and complex challenge for community mental health.
Ottawa lawyer Karen Capen examines the case of five Ontario physicians who faced charges of professional misconduct after a patient they cared for died in 1988. The investigation, which focused on the concept of "most responsible physician," serves as a cautionary tale for all doctors who share the care of a patient with colleagues.
New techniques have influenced the attitude to the autopsy and contribute to a de-emphasis on the importance of post-mortem examination. Since 1990, new Danish legislation has provoked a dramatic fall in the autopsy rate, which had already declined from 45% in 1970 to 35% in 1980. In the first half of 1990 the rate was 24% in the second half of that same year it had fallen to 16% (
The Danish National Institute of Health, 1992). The clinicians now seem to manage without the autopsy to confirm or correct their daily diagnostics. They also seem to be of the opinion that they do well without this "final checklist". The autopsy, however, is still an important tool in understanding, correcting and improving future diagnosis. Therefore, post-mortems should again be carried out as a matter of course and common practice. The following proposals are all aimed at obtaining a higher autopsy rate: The 1990 legislation on autopsy should be changed so that permission to perform a post-mortem can be given in due time, before the supposed death, preferably by the patient himself and obviously with the right to a subsequent change of mind. It is of great importance that the Public Health Service informs both the public and health workers in general about the nature and importance of the autopsy. Likewise, doctors and health workers in general should be educated in how best to give information to patients. Pathologists should, through a more uniform and exact practice, encourage the clinicians to a renewal of the close collaboration concerning the facts revealed by the autopsy, both in their everyday practice and in scientific projects in general.
Until recently, the Criminal Code of Canada, enacted in 1892, stood stalwart to social, political and technological changes, particularly with respect to the regulations pertaining to the management of the mentally ill offender. This became more definitely so with the enactment of the Canadian Charter of Rights and Freedoms (1984) as many regulations in the Code about mentally ill offenders contravened the mandates contained in the Charter. The Supreme Court of Canada's decision on Regina v. Swain spurred the Federal Government to bring the regulations on the mentally ill offender into line with the Charter. The result was the enactment of Bill C-30 which was intended to dramatically change the way in which forensic psychiatry was practised in Canada. This paper presents the Alberta findings from a multi-site evaluation commissioned by the Federal Department of Justice to judge the effects of Bill C-30 on forensic health care practices.
Health records data were used to compare utilization patterns from the year prior to the enactment of Bill C-30 with the year following. In addition, qualitative data were obtained from key clinical and legal informants outlining implementation difficulties that they had experienced.
Results support the judgement that Bill C-30 has not achieved its desired effects with respect to the length of the remand, and has resulted in an increased burden on hospitals and health care providers. In addition, an unanticipated finding was the increased use of the Mental Health Act which was considered to place forensic patients in a position of double jeopardy.
Comment In: Can J Psychiatry. 1995 Jun;40(5):223-47553539