Independent investigation reports

All providers of NHS funded services are required to be open and transparent with families and patients when things go wrong with their healthcare.

In April 2013 NHS England became responsible for commissioning independent investigations into homicides (sometimes referred to as mental health homicide reviews) that are committed by patients being treated for mental illness. The purpose of an independent investigation is to review thoroughly the care and treatment received by the patient so that the NHS can:

  • Be clear about what – if anything – went wrong with the care of the patient
  • Minimise the possibility of a reoccurrence of similar events
  • Make recommendations for the delivery of health services in the future

An independent investigation is carried out separately from any police, legal and Coroner’s proceedings. It is done by an independent, expert organisation, which is given access to all the information and reports about the individual patient’s care and treatment (within the usual patient confidentiality rules), and who can also request interviews with any NHS staff involved.

Criteria for an independent investigation

The criteria for an independent investigation to be carried out are:

  • As outlined in appendix 1, 3 and 4 in the NHS serious incident framework
  • To investigate the care and treatment of patients and establish whether or not a homicide could have been prevented and if any lessons were learned for the future
  • Increase public confidence
  • Provide an assurance framework for those trusts providing specialist mental health services and a platform for demonstrating learning from action plans.

A final report is prepared as part of the investigation process and this is shared with the NHS organisations that were responsible for the care of the patient, as well as the families of the victim and the patient. The NHS organisations involved are required to produce a plan that clearly sets out the actions they will take in response to the report from the investigation.

NHS England is then responsible for working with the NHS organisations and others, to ensure that all changes are made. The final part of the investigation process sees the publication of the report on the NHS England website, along with links to any action plans – this is so that any findings and conclusions drawn are shared as widely as possible.

Published independent investigation reports

Details are given of the independent investigation reports that have been published by NHS England from April 2013:

Find out more

Further guidance and information are available below: