1. INDEPENDENT INQUIRIES
Anselm Eldergill
British Journal of Health Care Management, May 1999, pp.198–203
INTRODUCTION
Health Service Guidelines require Health Authorities to hold an independent inquiry in cases where
a psychiatric patient kills someone (HSG(94)27). A purely internal investigation will likewise be
inappropriate if an incident, or series of incidents, calls into question existing procedures (Building
Bridges, pp.80–81). Such inquiries involve a great deal of work and are a daunting prospect for
anyone who has not previously had to arrange one, the more so because no legislation or
departmental guidelines have been issued which prescribe or recommend particular procedures.
This article aims to guide managers through the process, and it includes precedents which they
can use or adapt , such as terms of reference and job descriptions. Because the conduct of all
inquiries involves applying certain universal principles, and taking certain common steps, the
procedures described below will also be useful for managers working outside psychiatry. The
views and suggestions expressed in this article are those of the author. They are ‘Eldergill
Procedures’, and Health Authorities, and the chairmen of independent inquiries, are in no sense
bound by them.
GENERAL PRINCIPLES
An inquiry is a learning tool: its purpose is to learn any lessons which may minimise the possibility
of a recurrence of the tragic event, which is why the report is made to the bodies that have power
to change the way the service is provided. The outcome should be that any feasible improvements
are made, for the future good of everyone.
The focus of the inquiry is the care and treatment of a particular patient, rather than the triggering
event itself, so that the allocation of blame can only ever be an incidental effect of the inquiry
process. As regards the treatment and care provided immediately prior to the homicide, the
concern is with causation, not culpability. Retribution, and the expiation of wrong-doing, are
matters for the civil and criminal courts and for professional disciplinary bodies. Moreover, unless
insane at the time, the patient is responsible for his act, not the professionals who tried to help
him. Nor can there be any presumption that the fact of the homicide is evidence of poor treatment
or care. The occurrence of such a tragedy does not per se demonstrate any error of judgement on
the part of those discharging or supervising the patient. Even a very low risk, such as winning the
lottery, from time to time becomes an actuality.
Apprehension and fear on the part of those taking part must be minimised, so that the inquiry
does not interfere with the service being provided to other patients. Public inquiries inevitably
involve confrontation and those attending are often inhibited from being candid with the panel. A
private hearing is therefore to be preferred. The use of terms such as ‘hearing’, ‘witness’ and
‘evidence’ should be confined to the procedural part of the terms of reference. In other contexts, it
is less inhibiting to refer to meetings and discussions with those involved in the inquiry. Indeed,
referring to the process as a ‘service review,’ rather than as an ‘inquiry,’ may be more
constructive.
Given the usual remit, the problem is how to achieve procedural fairness in a process of decision-
making which involves commenting on professional conduct or, very rarely, criticising it. The
essential requirement is that the inquiry should be fair and just and be seen to be fair and just.
This requires providing some degree for protection to individuals whose credibility is strongly
impugned, and protecting them from unfair attack or condemnation. Subject to this overriding
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2. principle of fairness, an inquiry must balance various needs: thoroughness, speed, economy, and
informality. F amily members, carers and victims should be kept informed of the progress of the
inquiry and be supported by an independent person or organisation. They should be told the
content of any press releases before the information is made public. The Health Authority should
consider reimbursing the legal fees of family members if they wish to be accompanied to the
hearing by a lawyer.
THE COMMISSIONING AGENCIES
Although it is the relevant Health Authority that is required to hold the independent inquiry, it is
not uncommon for the local social services authority to be a joint commissioner. In such cases, the
social services authority will need to be a joint partner from the outset, agreeing the terms of
reference, panel appointments and financial arrangements. The appointment of an inquiry steering
committee, comprising a representative from each authority together with the inquiry chairman
and clerk, helps to ensure good co-ordination and communication.
APPOINTING A CHAIRMAN OF THE INQUIRY
The first step is for the Health Authority, in consultation with the local social services authority, to
appoint a legal chairman of the inquiry. The chairman’s functions are clear from the following job
description, which should be annexed to his letter of appointment. It is particularly important that
the chairman has authority to make decisions in between meetings of the panel members, if
unnecessary delays are to be avoided.
Role of the Legal Chairman of the Inquiry
The principal functions of the legal chairman are as follows:—
1. To ensure that the inquiry is conducted in accordance with the terms of
reference.
2. To chair meetings of the panel members and the private hearings at which
oral evidence is given.
3. To ensure that the inquiry is conducted fairly, that is in a manner which is
consistent with the principles of natural justice.
4. To provide guidance to the other panel members, and to witnesses who
give oral or written evidence, on matters of law.
5. To take all decisions about the conduct of the inquiry prior to, or between,
meetings of members of the inquiry panel.
6. To inspect, and decide how to respond to, all documents and
correspondence submitted to the panel of inquiry (other than correspondence
of a purely administrative nature).
7. To be responsible for the drafting of the final report, and to approve the
final report.
8. To draft (1) the case chronology summarising the relevant history; (2) any
Salmon-type letter, identifying heads of evidence upon which it is thought that
the witness may assist the inquiry; (3) any letter to a witness with which is
enclosed a part of the draft report containing criticisms of her/him; (4) the
letter to the Health Authority which accompanies the draft report; (5) any
letters to persons whose interests may be adversely affected by the report’s
publication.
9. To draft or approve all other documents and correspondence sent out by
or on behalf of the panel of inquiry, other than correspondence of a purely
administrative nature.
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3. 10. Following consultation with the clerk to the inquiry, to set a timetable for
each inquiry.
11. As soon as reasonably practicable, to meet with staff involved in the care
or treatment of the patients into whose cases the panel is inquiring.
12. Where considered necessary or desirable by her/him, to consult the other
panel members and the clerk to the inquiry about any decision concerning the
conduct of the inquiry.
The authorities should provide the chairman with a detailed information pack concerning the
organisation of local health and social services. The Health Authority should also write to the
patient and the deceased’s next-of-kin, advising them that an inquiry has to be held, and seeking
the patient’s consent, via his solicitors, to the release of relevant records. It is necessary to take
this action as soon as possible, subject to the possible caveat that the criminal court papers
should not be sought until after the conclusion of those proceedings (see below). The chairman
will need to be kept regularly informed about how these criminal proceedings are progressing.
This is particularly important if the case has been well publicised, because of the need to plan a
response to press coverage of the trial or sentencing hearing. Having appointed the chairman, the
two authorities can then agree the terms of reference with him.
AGREEING TERMS OF REFERENCE
The terms of reference should direct attention away from the ‘how and why’ of the homicide to the
more general issues of patient treatment and care. To this end, they should begin with a statement
setting out the ethos and purpose of the inquiry, emphasising that the inquiry process is supposed
to be constructive, and that the inquiry panel will do all it can to reduce anxiety amongst
participants. They should then go on to specify the inquiry panel’s remit and the procedure to be
adopted by the panel. The terms should be enclosed with the letters of appointment. General
issues to be considered at this stage are confidentiality (the extent to which an undertaking should
be given not to include information about the patient or his family in the inquiry report); whether
or not it is productive to ask witnesses to affirm; whether anonymity should only be offered to
those professionals who assist the inquiry; whether employees’ contracts of employment require
them to co-operate with the inquiry; and whether the final report will be published. Building
Bridges states that undertaking to publish the report enhances the inquiry’s credibility but that ‘in
exceptional cases it may not be desirable for the final report to be made public.’ Note that the
independence of the inquiry precludes the Health Authority reserving any right to have an observer
present at the hearings.
INDEPENDENT INQUIRY INTO THE CARE AND TREATMENT OF X
Purpose of the Inquiry
An inquiry is a learning tool: its purpose is to learn any lessons which may
minimise the possibility of a recurrence of the tragic event, which is why the
report is made to the bodies that have power to change the way the service is
provided. The outcome should be that any feasible improvements are made,
for the future good of everyone. The independent panel will do all they can
to reduce apprehension on the part of those taking part.
Terms of Reference
1 To examine all circumstances surrounding the treatment and care of
patient X by the Mental Health Services and Social Services, from 19— until
the death of Y. In particular:
w the quality and scope of his health, social care and risk assessments.
w the suitability of his treatment, care and supervision in the context of
— his actual and assessed health and social care needs
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4. — the actual and assessed risk of potential harm to himself or others
— the history of his medication and compliance with that medication
— any previous psychiatric history, including alcohol and drug misuse
— any previous forensic history
w the extent to which X’s care complied with statutory obligations, the
Mental Health Act Code of Practice, local operational policies, and relevant
guidance from the Department of Health [including the Care Programme
Approach (HC(90)23/LASSL(90)11], and the guidelines on supervision
registers (HSG(94)5) and discharge planning (HSG(94)27)];
w the extent to which X’s prescribed treatment and care plans were—
(i) adequate; (ii) documented (iii) agreed with him; (iv) carried out,
(v) monitored, and (vi) complied with by X.
2 To consider the adequacy of the risk assessment training of all staff
involved in X’s care.
3 To examine the adequacy of the collaboration and communication
between the agencies involved in the care of X (A NHS Trust, B Social Services
and X’s General Practitioner) or in the provision of services to him.
4 To consider the adequacy of the support given to X’s family by the
Community Mental Health Team and other professionals.
5 To consider such other matters as the public interest may require.
6 To prepare a report and to make recommendations to C Health
Authority, B County Council and A NHS Trust for the future delivery, quality
and range of care and treatment available to mentally ill people, including
the safety of mental health users, the public and staff.
Procedure to be adopted by the Inquiry
1 Every witness of fact will receive a letter before appearing before the
panel. This letter will ask them to provide a statement as the basis of their
evidence to the inquiry and inform them:
(i) of the terms of reference and the procedure adopted by the inquiry;
(ii) of the areas and matters to be covered with them;
(iii) that when they give oral evidence they may raise any matter they wish
which they feel may be relevant to the inquiry;
(iv) that they may bring with them a friend or relative, member of a trade
union, lawyer or member of a defence organisation or anyone else they wish
to accompany them, with the exception of another inquiry witness;
(v) that it is the witness who will be asked questions and who will be
expected to answer;
(vi) that they will be asked either to affirm or confirm that their evidence is
true;
(vii) that their evidence will be recorded and a copy sent to them afterwards
for them to sign.
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5. 2 Any points of potential criticism will be put to witnesses of
fact, either verbally when they first give evidence, or in writing later, and they
will be given a full opportunity to respond.
3 Written representations may be invited from professional bodies and
other interested parties regarding best practice for persons in similar
circumstances to this case and as to any recommendations they may have for
the future.
4 Those professional bodies or interested parties may be asked to
give oral evidence about their views and recommendations.
5 Anyone else who feels they may have something useful to contribute
to the inquiry may make written submissions for the inquiry’s consideration
and, at the chairman of the panel’s discretion, be called to give oral
evidence.
6 All sittings of the inquiry will be held in private.
7 The draft report will be made available to C Health Authority, B
Social Services and A NHS Trust for any comments as to points of fact.
8 The findings of the inquiry and any recommendations will be made
public.
9 The evidence which is submitted to the inquiry either orally or in
writing will not be made public by the inquiry, except insofar as it is
disclosed within the body of the inquiry’s report.
10 Findings of fact will be made on the basis of the evidence received
by the inquiry. Comments within the narrative of the report and any
recommendations will be based on those findings.
Detailed summaries of the guidance issued by the Department of Health, and the way in which the
circulars inter-relate, is set out in Eldergill, Mental Health Review Tribunals — Law and Practice
(Sweet & Maxwell, 1998).
APPOINTMENT OF A CLERK TO THE INQUIRY
All appointments must be acceptable to the chairman if the inquiry is to run smoothly, and must
have sufficient time to devote to the process. The next appointment will be that of a clerk to the
inquiry, who could be a solicitor or firm of solicitors, a Health Authority manager independent of
the service providers, or a specialist clerk. The panel members’ functions are executive and the
clerk’s administrative. In other words, it is for the members to decide how the inquiry will be
conducted, and the clerk’s role is to take whatever steps are necessary to give effect to their
decisions. Specifying the respective roles at the outset avoids misunderstandings later, which is
important because the team will be working together over a long period.
Role of the Clerk to the Inquiry
The principal functions of the clerk to the inquiry are as follows:—
General
1. To provide or arrange administrative, clerical and secretarial support to the
chairman and other members of the panel of inquiry.
2. To give effect to decisions made by the chairman and/or the panel of
inquiry.
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6. 3. To act in accordance with any instructions given to the clerk by the
chairman and/or panel of inquiry.
4. To assist the chairman in the exercise of her/his functions, as set out in
the document entitled, Role of the Legal Chairman of the Inquiry.
5. To advise the chairman where necessary about matters which need to be
addressed, and decisions which need to be made, in between meetings of the
panel of inquiry.
Particular
The clerk to the inquiry shall in particular ensure that:—
1. the patient’s consent to the release of relevant records is promptly
obtained, and that all relevant documentary evidence is then promptly sought
from those organisations, bodies and individuals previously or presently
involved in the patient’s care or treatment.
2. a draft timetable for each inquiry is promptly prepared and sent to the
chairman.
3. all information and communications concerning the inquiry which are not
of a purely administrative nature are promptly brought to the chairman’s
attention.
4. all letters and documents sent to the panel of inquiry which are not a
purely administrative nature are promptly copied to the chairman and, if s/he
so decides, to the other members of the panel of inquiry.
5. before any letter or document which is not of a purely administrative
nature is sent out by or under the name of the inquiry panel it is first promptly
copied to, and approved by, the chairman.
6. all documents and correspondence approved by the chairman are promptly
sent out .
7. all documents which the members of the panel of inquiry wish to copy to
each other, such as draft reports and letters, are promptly copied to the other
member or members.
8. all documentation and correspondence concerning the inquiry is retained
and properly indexed.
9. proper and adequate arrangements are made for meetings of the members
of the panel of inquiry, and for any other meeting held in the course of the
inquiry.
10. proper and adequate arrangements are made for private hearings and
meetings with witnesses, which includes ensuring that they are given adequate
notice of hearings and meetings at which their attendance is requested; (ii)
that they are properly informed of the venue; and (iii) that, where necessary,
they are given necessary assistance to enable them to attend.
11. proper and adequate arrangements are made for the prompt printing of
the panel of inquiry’s reports into the care and treatment of the patient.
12. all documents received or produced in connection with the inquiry are kept
in a secure place to which persons other than the clerk and the members of
the panel do not have access.
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7. 13. the proceedings of the panel of inquiry are kept confidential, and that
discussions with, and decisions made by, the chairman and other members of
the panel, are not disclosed to any other person or body except with the
chairman’s prior permission.
TIMETABLE AND OTHER APPOINTMENTS
Once the chairman and clerk have been appointed, a provisional timetable and budget may be
agreed with the authority, and arrangements made to provide the inquiry with necessary
accommodation, staff, and facilities (such as a transcript service). Provided that the panel
members are able to give the inquiry sufficient time, it is usually possible to abstract several
thousand pages of documents, hold an induction week, and hear all of the professionals involved
in the patient’s care and treatment, within six months of receiving the health and social services
records. Keeping to such a strict timetable means that panel members and professional carers
must work to very short notice, but it has the advantage of shortening the ordeal. Some inquiries
have taken more than four years to complete, and incurred costs of over £600,000, and this is
unacceptable. The appointment of a solicitor, or counsel, to the inquiry can be considered at this
point, but has the disadvantages of making the process more formal and expensive, and is
generally unnecessary if the chairman is a legal practitioner. The inquiry clerk will need a liaison
officer at the Health Authority: someone who can deal promptly with requests for documents to be
copied and sent out, and so forth. The venue for the hearings is often a local hotel, because this is
more informal and emphasises the inquiry’s independence of the service providers.
APPOINTMENT OF THE OTHER MEMBERS
The other members of the panel are usually a consultant psychiatrist and a social worker, although
in some cases it is desirable to appoint a nursing member. Clearly, the facts of the case dictate the
type of expertise which needs to be brought to bear on those facts. The terms of appointment can
include a paragraph which incorporates the job descriptions.
Role of the Members of the Panel of Inquiry
The principal functions of the members of the panel of inquiry are as follows:—
1. To ensure that the inquiry is conducted in accordance with the terms of
reference.
2. To attend, and participate at, meetings of the panel members and private
hearings at which oral evidence is given.
3. To inform the chairman about matters concerning the inquiry which they
consider should be discussed and dealt with at the next meeting of the panel
of inquiry.
4. To provide guidance to the other panel members, and to witnesses who
give oral or written evidence, on matters within their areas of expertise.
5. Where necessary, to advise the chairman about matters which need to be
addressed or decisions which need to be made in between meetings of the
panel of inquiry.
6. To consider all documents sent to them in connection with the inquiry and
to advise the chairman of any action which they consider should be taken to
address issues raised by those documents.
7. To identify with the chairman the potential witnesses and the issues
believed to be relevant to the inquiry, and any locations which need to be
visited.
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8. 8. To consider with the chairman the need to invite representations from (i)
expert witnesses and representatives from professional bodies, (ii) witnesses
of local knowledge, and (iii) statutory bodies, such as the Mental Health Act
Commission.
9. To assist in the drafting of the final report.
10. Where agreed with the other panel members, or in between meetings with
the chairman, to draft any other documents or correspondence.
11. As soon as reasonably practicable, to meet with staff involved in the care
or treatment of the patient into whose case the panel is inquiring.
THE INQUIRY PROCESS ITSELF
Because of the inquiry’s independent status, the remaining steps are taken by the inquiry team but
it is useful to summarise them for the benefit of those unfamiliar with the process.
Checklist for the Inquiry team
1. The clerk indexes the incoming documents, collating and paginating them
before taking six copies of each document: three for the inquiry members, one
for the clerk, one for witnesses to refer to, and one spare copy.
2. As the documentary evidence is received, the chairman considers its likely
relevance; prepares a case chronology (a lengthy document, usually about one
hundred pages long, that links the various records); and starts writing a draft
of the factual part of the report.
3. The chairman and clerk hold pre-inquiry meetings with the next-of-kin, the
patient, and the teams involved in the patient’s care. Meeting the professionals
at an early stage helps to allay any fears they may have about the inquiry, and
so minimises the risk of resignations from the services.
4. Having first notified the patient and the deceased’s next-of-kin, the Health
Authority issues a public statement announcing the inquiry, publicising its
terms of reference, and inviting interested parties to contact the inquiry with
their written observations. A formal announcement in the local press is more
dignified, and so preferable, to a press release.
5. The inquiry panel hold their first meeting. They agree guidelines for the
future conduct of the inquiry and plan the format of an induction week (see
(7)).
6. The chairman and the clerk finalise a timetable for the hearings.
7. An induction week is held, during which the inquiry team:
hold panel meetings at the beginning and end of the week;
visit key sites (the hospital and community facilities used by
the patient, and locations such as the exterior of the family home
and the local estate);
receive presentations from the Health Authority, NHS trust,
and social services, summarising the organisation of the services
and the local implementation of legislation and departmental
guidelines;
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9. obtain a number of independent service perspectives, from
the chairmen of any recently completed local inquiries, the Mental
Health Act Commission, the Community Health Council, MIND, the
National Schizophrenia Fellowship, etc (this saves time by drawing
on the expertise of those bodies which regularly scrutinise the local
services);
visit the patient, and speak with members of his current
treatment team (this alerts the panel to recent developments
relevant to their remit).
By the end of the week, the panel members will both have read the
documentation and have a reasonable understanding of the way in which
local services are organised and delivered. At their end-of-week panel
meeting they can define the main issues, and identify the professionals
whom they wish to see and/or from whom they would like a written
statement. They can also commission any additional documents referred
to during the presentations, or in the medical, social work, and other
notes; consider the need to receive evidence from expert witnesses; and,
where necessary, suggest revisions to the terms of reference.
8. The chairman drafts letters to prospective witnesses, identifying the
matters upon which it is thought that they may be able to assist the inquiry.
The letter should be as informal as possible. It will invite the witnesses to
submit written statements by way of response, and each witness will be invited
to attend a hearing and to give oral evidence on a given date. They will be also
be told of their right to bring a friend, relative, trade union representative or
lawyer to the hearing.
9. The hearings are held. It is often best to take the evidence in the following
order: (a) the patient (b) those responsible for patient’s care and treatment
since the offence; (c) family members; (d) other witnesses of fact; (e) expert
witnesses. The hearings enable witnesses to inform the panel of any
unrecorded events and observations, to deal with issues arising from the
documents, to tell the panel how the service has changed since the homicide,
and to make recommendations about the future delivery of services. There are
no formal opening procedures and the questioning is led by the most
appropriate panel member. After questioning, the witnesses are invited to
raise any matters which they consider to be relevant. Representatives should
be allowed to intervene if they are unhappy with the direction of questions;
have short adjournments to advise their clients; ask their client supplementary
questions after the panel have finished, in order to draw out facts not already
c o ve r e d .
10. Statements (or transcripts) are sent to the witnesses, for correction,
amendment and return. They are invited to submit a separate signed note if
they have had any after-thoughts.
11. Witnesses are recalled if there is a significant conflict of evidence or if one
witness has strongly criticised another.
12. The panel agree their provisional findings in relation to the individual’s
care and treatment.
13. These provisional findings are communicated to the commissioners at a
special inquiry steering committee meeting. If the commissioners consider
that immediate action is required, they can set about agreeing and
implementing an action plan. Everyone has a common interest in rectifying
obvious service shortcomings and such meetings have the additional
advantage that the action plan is incorporated in the final report: ‘We found
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10. shortcoming x, which the commissioners and service providers have dealt
with by taking actions y and z.’
14. If the various agencies agree, the panel complete their inquiries by
spending time with the teams, observing the way in which they organise and
co-ordinate their work, and inspecting documents detailing the present
implementation of the 1983 Act and departmental guidelines. This helps to
ensure that the final report is up-to-date and, if the homicide occurred some
considerable time ago, that the final report does not over-emphasise matters
of historic interest only or recommend actions which are no longer relevant.
15. The chairman drafts the report, which is then considered with his
colleagues, and amended as necessary.
16. The clerk sends copies of any passages which contain criticisms of a
witness to the relevant party, inviting a written response from them. They are
invited to make any further observations or submissions that they wish to
make.
17. The panel amends the report as necessary and then sends the draft report
to Health Authority for their comments on points of fact.
18. Having made any necessary amendments, the panel produce the final
report.
19. Letters are sent to the patient, family members, and anyone else whose
interests may be adversely affected by the report, advising them of the
publication date.
20. The findings and recommendations are published (and a press conference
held if necessary).
21. The authorities provide a formal response to the report.
22. The panel follows up its report, reconvening in private after six months, to
reconsider the responses, official and unofficial, to their recommendations.
KEY AREAS
It is useful briefly to consider the following key issues:
the legal position when the patient refuses to consent to the disclosure of his
records;
at what stage health and social services records should be obtained;
the importance of paginating the documents;
the extent to which those attending meetings should be directly questioned;
the format of the final report.
Absence of consent
If the patient refuses to consent to the release of his records to the inquiry team, their options
appear to be:
to hope that he will agree to meet with them at some stage, so that they can allay
his concerns;
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11. to ask each of the agencies involved to consider whether the public interest in
holding a full, independent, inquiry into the care and treatment of a patient who has
committed manslaughter overrides that patient’s usual right to bar disclosure of
documents concerning his care and treatment;
to ask the Department of Health to grant the inquiry formal powers, under section
125(1) of the Mental Health Act 1983;
to hold a very limited inquiry, which involves interviewing persons who are willing
to see the panel, and considering documents already in the public domain, such as court
transcripts and witness statements.
to abandon the inquiry.
The author’s own opinion is that in most cases the various health and social services agencies may
lawfully disclose to the panel material which it is necessary for the inquiry to see in order to fulfil
its terms of reference. This is for the reason already expressed, that the public interest in holding
a full, independent, inquiry into the care and treatment of a patient who has committed
manslaughter overrides that patient’s usual right to bar disclosure of documents concerning his
care and treatment. However, each agency will need independently to consider the point, because
each of them that discloses runs the risk of having to defend proceedings for breach of
confidentiality. Where only one agency decides that disclosure is not warranted then the
commissioners will need to consider applying to the High Court for a declaration. F aced with such
difficulties, the advantage of conferring on the chairman a time-limited, formal, power to
subpoena documents is that the NHS trust, social services authority, and other agencies may assist
the inquiry without any fear that they are incurring a legal liability. Put crudely, the rationale is that
if the Department of Health ‘requires’ an inquiry to be held then it should confer on the panel of
inquiry any powers that are necessary to enable it to fulfil the terms of reference.
Health and social services records
It is common practice not to disclose health and social services records to the panel, and not to
begin the independent inquiry, until the criminal proceedings have been concluded. Such
understandable caution is sometimes unhelpful. In particular, if the patient is unfit to plead, it may
delay the inquiry by 18 months. The effect is greatly to prolong the ordeal for the professionals
and the families of the patient and victim, and the eventual report may end up addressing a
service which, in the main, no longer exists. In principle, there is no reason why an independent
inquiry, held in private and overseen by a lawyer, should any more interfere with the criminal
process than the internal inquiries held immediately after the homicide. In many cases it will be
sensible for the panel to consider health and social services records, and to meet with
professionals to discuss care and treatment issues, as soon as possible. Once the criminal
proceedings have been concluded, they can then meet the patient and review the documents
arising out of those proceedings, presenting their report shortly afterwards.
Producing a bundle of documents
The need to rectify documents that have been copied to panel members without being adequately
indexed and paginated is a common problem, and leads to much wasted time and costs. The
preparation of a detailed chronology, and the need to refer professionals and panel members to
particular entries, necessitates that each page of the inquiry bundle has a unique number. This can
be achieved by filing the documents in twelve ring-bound volumes and then paginating each page
before taking copies.
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12. ARRANGING THE INQUIRY BUNDLES
Vol 1 General Practitioner records Vol 7 Post-offence prison records,
including the inmate medical
record;
Vol 2 Pre-offence hospital/ psychiatric Vol 8 Post-offence psychiatric reports
records
Vol 3 Pre-offence social services records Vol 9 Post-offence social work file
Vol 4 Pre-offence Probation Service Vol 10 Post-offence hospital records
records (nursing, psychological, special
investigations)
Vol 5 Police statements and exhibits; Vol 11 Documents produced by inquiry
panel members
Vol 6 Health and social services internal Vol 12 Correspondence an d
inquiry reports miscellaneous
So organised, the first page of the General Practitioner records becomes 1/001, and additional
records are inserted at the back of the relevant volume, paginated, copied, and distributed.
Questioning professionals and others
Everyone who assists the inquiry has a right to be treated with respect and it would be natural for
some of them to reflect upon the relative virtues of discretion and candour. Candour should be
encouraged and, in many ways, is the ultimate test of professionalism. The honest professional
who accepts that her or his practice, or local practice, might be improved upon in some respect
thereby ensures that the future direction of services is based upon a true and comprehensive
understanding of the current state of the services.
The final report
It is suggested that, as a general rule, the report should:
be kept short and be accompanied by an executive summary of the main points
(few people read long reports).
not disclose personal information unnecessarily.
concentrate on the terms of reference, and in particular local services, resisting the
temptation to address issues such as the content of future legislation (the authorities are
paying the panel members to inquire into the delivery of services to their local population).
be confined to points upon which the panel are agreed (if the panel cannot agree
that a particular reform is necessary then the need to reorganise the service should be left
to the local agencies).
start with a chapter which briefly sets out what the public can realistically expect in
relation to psychiatric treatment, social care, risk assessments, discharge planning, etc.
accept that all discharge decisions involve the assumption of a risk.
make clear the legislative and other constraints to which practitioners are subject,
so that treatment and care decisions are measured against a realistic yardstick.
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13. recommend a course of action for each and every problem (or explain why
improvement is impossible).
refer to commendable practices.
keep the number of recommendations short (if six key recommendations will
account for 95% of the improvements that result from the inquiry, they should not be lost
amongst — and local practitioners should not be subjected to — a welter of minor
recommendations about form-filling, and so forth).
FUTURE DEVELOPMENTS
The arrangements set out in Health Service Guidelines HSG94(27) are being reviewed. The
Government has indicated that the new Commission for Health Improvement is likely to have a role
in assisting with inquiries held under the National Health Service Act 1977. It is possible that the
Commission will also assume a responsibility for inquiries following homicides, although such
arrangements would need to ensure that the delivery of social services, and not just health care,
are subject to review.
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