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External review of all Independent Investigations following Mental Health Homicides

South West
Published 01 Jan 2013

To ensure that NHS England continues to commission high quality independent investigations that influence and support system wide development and improvement,  NHS England commissioned an external review of all Independent Investigations following Mental Health Homicides (IIMHH) and the national governance arrangements underpinning this work. The review considered investigations undertaken between 2013 – 2017. NHS England have accepted the report findings and have developed an action plan which

Report PDF NHS England Source
Acceptance Status
No Response Published 9
Total Recommendations 9
About this data

Acceptance Status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

Recommendations (9)

1 NHS England
No Response Published
Recommendation
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality … Read more
2 NHS England
No Response Published
Recommendation
It is recommended that a national repository is provided to deliver a single access point for IIMHH reports, and that publication standards are developed to provide complete publication of the IIMHH, the synopsis and the recommendations for public access Read more
3 NHS England
No Response Published
Recommendation
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the … Read more
4 IIGC
No Response Published
Recommendation
It is recommended that the IIGC continues to function as the strategic governance group for Independent Investigations into mental healthcare related homicides, and makes the necessary linkages with other national programmes of work i.e. mental health and quality and safety. Read more
5 IIGC
No Response Published
Recommendation
It is recommended that the IIGC identifies the strategic co-dependencies with agencies such as police, probation, prison engaged with mental health services to optimize the learning and improvement and to provide a platform for joint working at the strategic level. Read more
6 IIGC
No Response Published
Recommendation
It is recommended that the IIGC should alert the National Quality Board and the Quality Assurance Group of the complexities and challenges of sharing learning and implementing improvement across the wider systems and with those partners identified by recommendation four. Read more
7 IIGC
No Response Published
Recommendation
It is recommended that the IIGC should develop additional metrics and key performance indicators to provide assurance of regional adherence to quality as well as process requirements of Independent Investigations and the Serious Incident Framework.
8 IIGC
No Response Published
Recommendation
It is recommended that the IIGC should develop measures to demonstrate the impact and outcomes of the Independent Investigation process, with particular regard to; learning, service improvement, policy development and the experience of all affected families and carers. Read more
9 IIGC
No Response Published
Recommendation
It is recommended that the outcomes of the perpetrator characteristics and profile identified in this review be shared with the appropriate commissioners and service providers for the future commissioning of services.