Independent investigation reports
In accordance with national guidance NHS South East Coast is responsible for commissioning an independent investigation following a serious mental health adverse event. A similar process is followed when independent investigations of patient safety incidents are required within any NHS organisation.
The purpose of the independent investigation is to examine all the circumstances surrounding the care and treatment provided in each case to identify any errors or shortfalls in the quality of service and to make recommendations for improvement as necessary.
When is an independent investigation necessary?
As the Strategic Health Authority (SHA), NHS South East Coast is responsible for determining when an independent investigation is necessary and appointing an independent investigation team where it is deemed to be so. We also agree the terms of reference for independent investigations and publish the resulting reports, ensuring that there is a process for subsequent action to address any issues raised.
An independent investigation may be undertaken in the following circumstances:
- when a homicide has been committed by a person who is or has been under the care of specialist mental health services in the six months prior to the event
- when it is necessary to comply with the government’s obligations under Article 2 of the European Convention on Human Rights. Whenever a government agent is, or may be, responsible for a death, there is an obligation on the government to carry out an effective investigation
- where the SHA determines that an adverse event warrants independent investigation, for example if there is concern that an event may represent significant systemic service failure, such as a cluster of unexpected deaths including suicides.
