When Should They Start?

Official government guidance says the independent investigation should start ‘as soon as possible’ after the incident. European law says such investigations should be ‘prompt’.

This often doesn’t happen because many health authorities just don’t like doing them.

They upset the staff, they cost money and they bring unwelcome media attention. Very often they highlight failings which should have been dealt with already – which is highly embarrassing.

(The right of victims’ families to know what happened doesn’t seem to feature very highly on their agenda).

Dragging their feet

So although they have an absolute duty to commission inquiries, very often SHAs drag their feet for as long as possible. In July 2007 things got so bad that the Chief Executive of the NHS even had to restate the existing guidance by writing to all SHA Chief Executives to remind them of their responsibilities.

One inquiry published in January 2010 concerned the murder of a child in June 2003 – some six and a half years earlier. The report had been completed in December 2007 yet remained with the SHA for over two years before final publication.

And whilst some regions have started to investigate properly since being told to pull their finger out, others are still failing to launch full and proper investigations.

Can’t be bothered

Sometimes they don’t even hold them at all.

In April 2008 a study by Manchester University looked at a sample of mental health homicides where an independent inquiry should have been held.

They found more than 30% of qualifying cases didn’t actually receive one. And they found no valid reason why they didn’t.

Spurious delays

Often SHAs will claim they can’t begin the independent inquiry because the court case hasn’t been completed.

This is often just a red herring and an excuse for delay.

The Government guidance is quite clear – it says if legal proceedings are ongoing the health authority should just talk to the Police and Crown Prosecution Service to make sure their investigations don’t prejudice the court case.

If there’s any serious doubt that the accused actually did commit the crime then of course it will be prudent to wait to see if they are convicted or not.

But in very many cases of killings by the mentally ill, there’s no doubt at all that the defendant committed the act.

Sometimes they even confess to it.

So the debate is not about whether they did the act – it’s about how responsible they were for it, whether they were in their right mind at the time, and whether they should be convicted of murder or manslaughter.

In such cases there is absolutely no reason to delay starting the independent inquiry.

At the very least the inquiry panel can be selected, terms of reference can be drawn up and the available documentation collected.

Consequences of delays

Delaying the inquiry process means

  • documents, recall of the events and witnesses will all be more difficult to find, diminishing the quality of the evidence so the inquiry will not be as thorough and robust as it should be
  • potentially unsafe practices and treatments are being tolerated for longer than is absolutely necessary.
  • lessons aren’t being learned, and
  • patients, their families, NHS staff and the wider public are all put at unnecessary risk.

No oversight

Although the National Patient Safety Agency is the responsible agency to ensure the NHS learns from its mistakes, and the Care Quality Commission has powers to ensure health services are of a good standard, neither body appears to have monitored, investigated or even questioned, the repeated failure of Strategic Health Authorities to commission homicide investigations as they should.

In the absence of any effective oversight, health bodies will continue to drag their feet and put the public at risk.


‘Soon as possible’ from Department of Health 2005 Guidance p2


‘Prompt’ from European Court of Human Rights, in Liberty briefing


See also: ECHR JUDGMENT: PAUL AND AUDREY EDWARDS v. THE UNITED KINGDOM (Application no. 46477/99) Strasbourg, 14 Mar 2002

July 2007 NHS Chief Executive’s letter


January 2010 inquiry report NHS North West: Report of the Inquiry into the Death of Child A (Chloe Fahey). In particular – paragraph 10 of the Board Paper


Manchester University study (April 2008) p 3 and 13


The 30% figure is likely to be a considerable underestimate as it came from a small sample of the cases receiving most intensive mental health care. It’s likely many more of those receiving less intensive services would fail to receive independent investigation. (see Case Study NHS North West)

‘Spurious Delays’ from Correspondence with NHS South West, various dates 2008.

Guidance quite clear, from Department of Health 2005 guidance (above)

Consequences of delays.

See for example: Report into the Health Care and Treatment of Anthony Stewart, NHS North East, November 2008 p25

“The inquiry was held almost four years after the killing. Witnesses had difficulty in giving a clear account and on occasion it was apparent that recollections may have been affected or clouded by the passage of time. It was also difficult to obtain relevant policies and documentation. The public interest and the need to obtain best information and evidence demands that any inquiry should take place as soon as possible after the relevant events.”

Role of National Patient Safety Agency http://www.nrls.npsa.nhs.uk/

Role of Care Quality Commission from http://www.cqc.org.uk/aboutcqc/whatwedo.cfm

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