Independent investigations

Strategic Health Authorities must commission independent investigations (e.g. when a homicide has been committed by a patient) in accordance with Government guidance. [This page needs to be updated.]


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

Investigation reports

  • Peter Bryan. 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:
  • Timothy Crook ('X') and Michael Harris ('Y'):
  • Connor Sparrowhawk:
  • Leslie Gadsby:

Dept of Health - the guidance



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