THE violent, horrific deaths caused by Valdo Calocane in Nottingham and by Axel Rudakubana in Southport are subject to public inquiries.

The tragedies have led to understandable concerns being voiced about public safety, professional competence and the adequacy of mental health services. It has been suggested that it is necessary to detain more people in psychiatric units.

In November 2023, Calocane admitted three counts of manslaughter on the ground of diminished responsibility and three counts of attempted murder. He has paranoid schizophrenia and was sentenced to indefinite detention in a high-security hospital.

On July 29 2024, a mass stabbing occurred in Southport. Three young girls aged between six and nine died; several other children, and two adults, were critically injured. Rudakubana was aged 17 at the time and he had an autism spectrum disorder. On January 23 2025, he was sentenced to life imprisonment, with a minimum term of 52 years.

Independent homicide inquiries enable bereaved families and the public to know the full circumstances, whether what happened could have been prevented, and whether more can be done to minimise the risk of such tragedies recurring.

After 40 years in mental health practice, which includes chairing many homicide and suicide inquiries, I have some general observations.

It is a remarkable fact that every war and act of cruelty that has ever taken place, and every work of art or act of love and devotion, was conceived within, and executed at the instigation of, a small object weighing three pounds — the brain.

Although a person’s conduct is the external expression of internal processes within their brain, it is not practical to see every harmful act as the product of faulty thought processes that necessitate psychiatric treatment and excuse the individual of legal responsibility. Unless the perpetrator was not guilty of a crime by reason of insanity, they are legally responsible for the death they caused, not the professionals who tried to help them, even if errors were made.

Those we describe as “patients” are themselves members of the public. They are important individuals, no more and no less than any other individual. Individuals who suffer, who will certain ends for themselves and their loved ones and not others, who wish to develop and to be happy and fulfilled. Each is a citizen. That is, a person whose needs and interests the government exists to serve. A brother, sister, mother, father, or ourselves at some stage of our life. Liberty and autonomy have the same importance for them as for anyone else.

Parliament has usually attempted to devise mental health laws that balance three things: individual liberty; bringing treatment to bear where treatment is necessary and can be beneficial; and protecting individuals. However, you cannot have maximum liberty and maximum safety. Freedom comes at a price in terms of safety, and safety bears a price in terms of freedom. It is not possible to have it both ways. The more autonomy all of us have, the more at liberty we are to harm ourselves and others.

“Mental illness” carries a stigma that “physical illness” does not. In reality, there is no difference. The brain is a physical organ of the body no less than the heart or liver. We should not demonise mental illness. The press’s tendency to use medical adjectives to define the person is insulting and prejudicial, and akin to describing a person with leprosy as a “leper.” To refer to someone as a “schizophrenic” or as a “paranoid schizophrenic” is to imply that their personality has been so distorted by their illness that the latter is now the feature which most tellingly defines them as an individual.

People with a mental illness make a small contribution to violence in society. Variables such as male sex, young age and lower socio-economic status proportionately make a much higher contribution. The enduring impression after spending many years visiting psychiatric wards is not one of fear or dangerousness, but of suffering and an often disarming kindness on the part of those who have lost their liberty.

Although professionals must assess risk, it is usually difficult or impossible to predict outcomes. A medical superintendent at Broadmoor Hospital once said to me: “We know that nine out of 10 patients don’t need to be here. We just don’t know which nine.” That remains true.

It is obvious from reading homicide inquiry reports that legislation has a limited role to play. Had the professionals foreseen what was about to happen, they already had powers to intervene under the Mental Health Act. That they did not intervene was due, not to any lack of legal powers, but to the fact that they did not foresee what was about to occur. Yet no amount of new legislation can improve foresight.

It is a fiction that all homicides and suicides can be prevented by good or adequate mental healthcare. This is no truer of mental-health-related deaths than it is for non-mental-health related murders. Even a very low risk, such as winning the lottery, from time to time becomes an actuality.

A risk can in theory be measured and is the basis of actuarial prediction — in theory because in practice all of the critical variables never are known. The risk depends on the situation but the situations in which the person may find themselves in the future can only be speculated upon. Furthermore, small differences in a key variable can result in vastly different behaviours and outcomes: just as a sudden change in the physical state of water into steam or ice occurs with the rise or fall of temperature beyond a critical level so the addition of a small additional stress on an individual may have a profound effect on their mental state or behaviour.

Although it is important to put in place an adequate system for supervising a person who poses a significant risk to themselves or others, this approach is not fail-safe: it is based on the assumption that most episodes of harm do not erupt like thunderstorms from clear skies. In reality, as with weather systems, only the pattern of events for the next 24 hours can usually be forecast with some accuracy; and contact with supervisors is less regular than that.

All harm and violence takes place in the present and the past is a past — and so unreliable — guide to present and future events. As Bertrand Russell once put it, the man who has fed the chicken every day throughout its life at last wrings its neck instead.

Mental health professionals and judges must have sufficient courage to accept that all decisions in mental health are risk-laden and not be paralysed by these limitations or practise too defensively. A ship is safest in harbour but that is not what ships are for. Those who chair public inquiries into homicides and suicides must also start by acknowledging that mental health practice is risk-laden.

Anselm Eldergill was until recently a judge in the Court of Protection. He is a solicitor and an Honorary Professor at Queen’s University Belfast.