What is a Homicide Inquiry?

Who does them? What do they do? Are they any good?

Homicide Inquiries

If a patient has been in contact with mental health services in the six months before they killed someone, the government requires NHS England to commission an Independent Inquiry or investigation into the event.

They also have to commission an inquiry if it is thought that there were systemic problems within the trust, or, if someone working for the state was involved or somehow contributed to the death.

NHS England will first consider the mental health trust’s own internal investigation report before agreeing to hold an independent inquiry.

Who does the inquiry?

The inquiry will be undertaken by people who don’t work for the SHA or the local mental health trust. They should, in theory, be fully independent.

Typically the inquiry team will include a solicitor or barrister, a consultant psychiatrist, and possibly someone with a background in nursing or social services.

The mental health professionals appointed to the panel will however inevitably come from other mental health trusts where patients have also committed murders. Some think this can lead some panel members to be much more sympathetic to poorly performing mental health staff than to the families of the victims.

What do they do?

Homicide Inquiries examine the care and treatment of a mental health patient involved in a killing to see if the care was appropriate and of good quality. They investigate if local and national guidelines were followed and whether any lessons can be learned to help prevent such homicides happening again in the future.

The inquiry panel

  • reviews all available documentation,
  • talks to witnesses (but only if they agree),
  • writes a detailed account of the case (usually as a timeline of what happened when) and
  • makes comments and judgements about the quality of the care received by the perpetrator.

The hearings are held in private.

Often Independent Inquiries don’t discuss the victim or what happened to them in any detail – they are mainly concerned with what happened to the perpetrator.

The inquiry panel will write a report – which is usually published – and which will usually include recommendations for improvements in services.

If done properly, Inquiries can provide extremely useful information to the families of victims trying to understand what happened to cause their loved one to lose their life.

Are they any good?

The quality of Independent Inquiries is hugely variable.

Some are excellent and do a robust and thorough analysis of the background and causes of the incident. They provide much useful information in a fair and open way which can go a long way to help families and support real change.

Such Inquiries include those into the care and treatment of Matthew Newland, Garry Taylor, and Daniel Gonzales amongst others.

Others are less good and just seem to accept the trusts’ own internal investigation without much serious questioning or analysis at all.

Their main aim appears to be more in reassuring NHS staff and avoiding criticism rather than in thoroughly investigating the incident itself.

The quality of the inquiry report depends largely on the independence of the chairperson and the other members of the inquiry panel.

Although there are some honourable exceptions, the general rule of thumb seems to be – the more professional involvement the chair has had previously with mental health services, the less rigorous and incisive the report is likely to be.


National Patient Safety Agency. Independent investigation of serious patient safety incidents in mental health services. Good Practice Guidance, February 2008.


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