Strategic Health Authorities must commission independent investigations (e.g. when a homicide has been committed by a patient) in accordance with Government guidance.

Criteria

The quotation below is from the Independent investigation of adverse events in mental health services guidance.

An independent investigation should be undertaken in the following circumstances:

• when a homicide has been committed by a person who is or has been under the care, i.e. subject to a regular or enhanced care programme approach, of specialist mental health services in the six months prior to the event.
• when it is necessary to comply with the State’s obligations under Article 2 of the European Convention on Human Rights. Whenever a State agent is, or may be, responsible for a death, there is an obligation on the State to carry out an effective investigation. This means that the investigation should be independent, reasonably prompt, provide a sufficient element of public scrutiny and involve the next of kin to an appropriate extent.
• where the SHA determines that an adverse event warrants independent investigation, for example if there is concern that an event may represent significant systemic service failure, such as a cluster of suicides.

External links

Recent inquiry reports

• Independent reports published into care and treatment of Peter Bryan. He murdered Brian Cherry in February 2004, was subsequently admitted to Broadmoor and in April 2004 inflicted fatal injuries on Richard Loudwell. The two reports relate to East London NHS Foundation Trust and West London Mental Health Trust respectively. See:

• NHS London website: Independent reports published into care and treatment of PB - 3/9/09
• CQC reaction to the Broadmoor incident

• Timothy Crook ('X') and Michael Harris ('Y'):

• Stephen Morris, 'Killings by mental health patients in Swindon were preventable, say reports' (Guardian, 23/11/11)
• BBC, 'Killings in Swindon by mental health patients "avoidable"' (22/11/11)
• Avon and Wiltshire MH Partnership NHS Trust, 'Trust accepts reports’ findings and apologises' (press release, 22/11/11)
• South West SHA and East Midlands SHA, 'Independent Investigation into the Care and Treatment Provided to Mr. X by the Lincolnshire Partnership NHS Foundation Trust and the Avon and Wiltshire Mental Health Partnership NHS Trust' (22/11/11)
• South West Strategic Health Authority, 'Report of the Independent Investigation into the care and treatment of Mr MH' (22/11/11)

Dept of Health - the guidance

• HSG (94)27: Guidance on the discharge of mentally disordered people and their continuing care in the community - 10/5/94

• Independent investigation of adverse events in mental health services - 15/6/05 - This guidance replaces paragraphs 33 -36 in HSG (94) 27, (LASSL(94)4), concerning the conduct of independent inquiries into mental health services.

• LASSL (94)4: Guidance on the discharge of mentally disordered people and their continuing care in the community - published 1/5/94

SHA websites

• NHS London: list of independent inquiry reports

• NHS North East: list of independent inquiry reports

Other

• George Szmukler, 'Homicide inquiries: What sense do they make?' (2000) 24 Psychiatric Bulletin 6