Different Types of Investigation

There are three different types of health service investigations following a murder or manslaughter by a mental health patient.

Immediate Review

The ‘Initial Service Management Review’ is undertaken by a senior local manager or health professional of the Mental Health Trust, usually within 72 hours of the incident, to see whether there is any urgent problem that needs fixing quickly to ensure safety.

Notes and documents should be secured and potential witnesses identified so the case can be investigated properly later.

This review is an internal document and is never released to the family.

Internal Investigation

This is a more in-depth investigation by the Mental Health Trust into the background and circumstances of the case.

It’s supposed to be completed within three months of the incident itself.

Usually senior local managers and clinicians look at the patient’s records, interview staff involved, and see if the care and treatment the patient received was as good as it should have been.

The investigation should also identify any underlying causes which may have contributed to the killing and make recommendations for any improvements.

They will write a full report on the case which will go to the regional Strategic Health Authority for consideration.

The problem with Internal Investigations is they always involve people from the same organisation investigating themselves.

For any number of reasons, this often means their report is not as rigorous or thorough as it could be.

Government guidance from the National Patient Safety Agency is that internal investigations should ‘usually’ be shared with the families of the victims – though very often this doesn’t happen.

Independent Homicide Inquiries are covered in the next section.


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

Problems with internal reports
A number of Independent Inquiries have commented on the poor quality of internal reports:

NHS London. Philip Theophilou Inquiry (2010) p 200.
“The findings of the internal inquiry in the PT case were neither accurate nor reliable”.

Mental Welfare Commission for Scotland, Gary Ward Inquiry (p8) :
“Our investigation found that the [internal] critical incident review related to Mr F’s case fell well short of an expected standard.”

NHS Yorkshire and Humber. George Garnett Inquiry (2004/680) p3 :
“The analysis…revealed: An internal report that was not at all analytical and did not evidence the degree of critical appraisal expected in the level of investigation.”

NHS West Midlands. Keith Macdonald Inquiry (p57) found faults with the internal inquiry’s conduct of interviews, record keeping, timing, contact to families, openness, and learning;

NHS West Midlands Kevin Roberts Inquiry (p42 – para 109)
“The internal review process undertaken by the Trust was carried out by a panel of four people, two of whom had either had clinical responsibility for the patient, or had managerial responsibility for the funding panel managers at the relevant times. It is the view of the independent investigation that both of these people had the potential for, or actual real conflict of interests. It is the view of the independent investigation that the internal review did not adequately examine the failings of the funding panel to conduct itself appropriately.”

NHS East Midlands: Khalid Peshawan Inquiry (p124/5)
“The internal review did not adequately explore all of the issues relating to the care and treatment of Mr. X…..None of the Internal Review Team members had been involved in an exercise of this kind before” It found the internal report’s findings were ‘a little superficial’ And when the internal investigation was completed the Inquiry found “Most of the clinical witnesses …had not seen a copy of the completed internal review report and could not identify any subsequent changes in practice that had occurred as a result of the ensuing action plan.”

NHS East of England: John McFarlane Inquiry (p11) Nov 2011
“It has been established that the Trust investigation process was sub-optimal… The processes were not robust, staff felt out of their depth and a robust Serious Untoward Incident Investigation was hampered by lack of multi-agency working with Suffolk Police.”

NHS North West. Jonathan Mills Inquiry (p134) Sept 2011
“The Independent Investigation Team found that the Trust Internal Investigation following the incident did not comply with Trust policy. The process and the conclusions of the investigation were very limited and failed to include the families of the victim or the perpetrator as they should have been… Managers who had accountability for the service at the time were not included in the investigation and had not seen the report. There had been no dissemination of learning from the incident”

According to Verita, (a company which has carried out many independent investigations)
“We… know from first-hand experience that the quality of the internal incident report is sometimes poor, making it difficult for providers to learn from past mistakes…”

Learning does not always follow from these Internal reports.

NHS East of England – Review of four homicides in North Essex Partnership Trust p 15 (March 2010)
“It is of concern that some of the themes highlighted in the first internal investigation in 2003, in particular risk assessment, risk management and information sharing, were repeated in the other incidents which happened some two years later. This reflects a failure on behalf of the trust to learn lessons in order to prevent similar incidents re occurring. ”

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