View source for Inquiries - Key documents

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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An independent review of the Independent Investigations for Mental Health Homicides in England (published and unpublished) from 2013 to 2017, NHS England, October 2019, Section one: Executive Summary , Section two: Main report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
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