Inquiries - Key documents
When Dave Sheppard retired in 2020 he kindly gave me permission to publish the contents of his website (originally named after his firm, "Dave Sheppard Associates", then called "MHAandMCA"). It is a treasure trove. I've not had time to prepare everything for publication but have put the main headings online: let me know if you would like a copy of anything listed.
Independent investigations following homicide, NHS England (external link)
Hundred families (external link)
National Confidential Inquiry into Suicide and Safety in Mental Health - Annual Report, December 2019
Earlier reports; 2018 ; 2017 ; 2016; 2015; 2014; 2013; 2012 ; 2011 ; 2010 ; 2009
An independent review of the Independent Investigations for Mental Health Homicides in England (published and unpublished) from 2013 to 2017, NHS England, October 2019, Section one: Executive Summary , Section two: Main report
Learning from deaths, A review of the first year of NHS trusts implementing the national guidance, CQC, March 2019
Findings from a thematic analysis of reviews into adult deaths in Wales: Domestic Homicide Reviews, Adult Practice Reviews and Mental Health Homicide Reviews, March 2018
Suicide by Children and Young People, July 2017
National Guidance on Learning from Deaths, March 2017
A toolkit for specialist mental health services and primary care, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, February 2017
Operating Policy for commissioning and managing independent investigations for the NHS in England, version 18, NHS England, February 2017
Domestic Homicide Reviews: Common themes identified as lessons to be learned, Home Office, December 2016
Multi-agency statutory guidance for the conduct of domestic homicide reviews, Home Office, December 2016
Domestic Homicide Review - Case Analysis, Nicola Sharp-Jeffs and Liz Kelly, June 2016
Suicide by children and young people in England, National Confidential Inquiry into Suicide and Homicide, May 2016
Lessons from independent homicide reviews, Verita, 2015
Working together to safeguard children, A guide to inter-agency working to safeguard and promote the welfare of children, HM Government, 2015
A practical guide for families after a mental health homicide, Hundred Families, 2015
Article 2 of the European Convention on Human Rights and the investigation of serious incidents in mental health services, 2015
Serious Incident Framework - frequently asked questions, NHS England, 2015
Serious Incident Framework, NHS England, 2015
Domestic Homicide Reviews: Common themes identified as lessons to be learned, Home Office, 2013
Multi-agency statutory guidance for the conduct of domestic homicide reviews, Home Office, 2013
Criteria for considering domestic homicide review reports, Home Office, 2013
Serious Incident Framework, NHS Commissioning Board, 2013
Domestic Homicide Review Toolkit: Guide to overview report writing, Home Office, 2012
John H.M. Crichton: A review of published independent inquiries in England into psychiatric patient homicide, 1995-2010, Journal of Forensic Psychiatry & Psychology, Volume 22, Issue 6, pp. 761 - 789, 2011
Second report on independent investigations following homicide by those in the care of mental health services, 2010
Learning from experience, Report of consultancy to support the compilation and analysis of learning from the 2002-2006 London mental health homicide reviews and analysis, Caring Solutions, 2008
First report of the Inquiry's examination of independent investigations following homicide by those in the care of mental health services, 2008
Independent investigation of serious patient safety incidents in mental health services, Good practice guidance, National Patient Safety Agency, 2008
Root Cause Analysis Investigation Tools, National Patient Safety Agency, 2008
Letter from SHA Chief Executive re Independent investigation of adverse events in mental health services, 2007
Suki Desai, Accounting for difference: analysis of nine murder inquiry reports involving black people with mental health problems, Diversity in Health and Social Care 2006;3:203-10
Guidelines for the NHS. In support of the Memorandum of Understanding: Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and the Health & Safety Executive, 2006
Memorandum of Understanding: Investigating patient safety incidents involving unexpected death or serious untoward harm published by Department of Health, Association of Chief Police Officers, Health and Safety Executive, 2006
Avoidable deaths - Five year report of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2006
Review of Homicides by Patients with Severe Mental Illness, Tony Maden, Professor of Forensic Psychiatry, 2006
Independent investigation of adverse events in mental health services, 2005
Paul and Audrey Edwards v the United Kingdom, European Court of Human Rights, 2002
Melissa McGrath and Dr Femi Oyebode, Qualitative analysis of recommendations in 79 inquiries after homicide committed by persons with mental illness, Journal of Mental Health Law, 2002
George Szmukler, 'Homicide inquiries: What sense do they make?', Psychiatric Bulletin, 2000
Dave Sheppard, Learning the Lessons: Mental Health Inquiry Reports published in England and Wales between 1969-1996, Zito Trust, 1996
If things go wrong (paras.33-36), Guidance on the discharge of mentally disordered people and their continuing care in the community, HSG(94)27, Department of Health, 1994
DSA archive