Looking Through the Reeds: System-Theorising the Independent Homicide Inquiry

  • David Horton

Student thesis: Phd


Independent Homicide Inquiries (IHIs) investigate homicides committed by persons in receipt of mental health services. They explore the potential causes of these events in order to learn lessons and improve the future provision of mental health services. IHIs decipher complex mental health care histories that, on further inspection, appear resistant to linear causal theories about what actually happened. IHIs are thus constantly open to indeterminacy in their findings regarding what caused the homicide, whether it was predictable and whether it could have been prevented. This is important because IHIs use these findings as a platform for changing the way mental health services are provided.The present thesis implements a theoretical framework, based on Niklas Luhmann's systems theory, which explains why this problem occurs. Luhmann argued that reality is constructed by distinctly meaningful social systems of communication based around specific social codes. He furthermore posits that decisions are open to continual objection, disagreement and regret. Not only can decisions be decided otherwise by virtue of being decisions, but that social systems will observe decisions in different ways. Decisions can always be observed to be objectionable, incorrect and regrettable after they have been taken. Using this framework, this thesis asks how IHIs retrospectively understand the provision of mental health services in the cases that appear before them. It argues that IHIs construct their investigation and findings using specific social communications that give their observations specific meaning. In light of an expanding, interconnected decision making edifice that comprises mental health services however, the link between identifiable decisions and acts of homicide is obfuscated by 'systems and processes'. This, in turn, obfuscates individual agency. The thesis consequently calls for a revision of what it means to hold mental health professionals to account in the aftermath of homicide.
Date of Award1 Aug 2014
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorKirsty Keywood (Supervisor) & Toby Seddon (Supervisor)


  • Risk
  • Independent Homicide Inquiries
  • Accountability
  • Systems Theory
  • Luhmann

Cite this