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Investigation

What we do

The role of the investigation team is to undertake focussed reviews of healthcare organisations or services in response to concerns arising from a particular incident or incidents, dependent upon seriousness and/or frequency of occurrence.

Although we do not investigate individual complaints we will consider investigating issues that indicate wider failings within the NHS. We carry out investigations when a death occurs in prison, or when a patient known to the mental health services is involved in a homicide.

Investigations may arise as a result of an NHS Organisation(s) self referral, HIW deciding to investigate as a result of issues brought to light during screening of data / information or inspection, or following request for an investigation from, for example, a member of the public, another inspectorate, the police or the Welsh Government.

Reviews of Homicides where Perpetrator was a Mental Health Service User

In circumstances where a patient known to Mental Health Services is involved in a homicide, the Welsh Government may commission an independent external review of the case to ensure that any lessons that might be learnt are identified and acted upon. As of January 2007 these independent external reviews have been conducted by Healthcare Inspectorate Wales.

The terms of reference for such reviews are to:

• Consider the care provided to the perpetrator as far back as his/her first contact with health and social care services.
• Provide an understanding and background to the fatal incident that occurred.
• Review the decisions made in relation to the care of the perpetrator
• Identify any change or changes in the perpetrator’s behaviour and presentation
• Evaluate the adequacy of any related risk assessments and actions taken leading up to the incident
• Produce a report detailing relevant findings and setting out recommendations for improvement
• Work with key stakeholders to develop an action plan (s) to ensure lessons are learnt from the case

The reviews we have undertaken have highlighted common themes and concerns in relation to the sharing of information across statutory bodies, risk assessment, risk management and the availability of services for individuals with a personality disorder. 

Report of a review in respect of Ms A and the Provision of Mental Health Services, following a Homicide committed in October 2005
Action Plan in response to HIW report 'Ms A' (Draft work in progress)

Report of a review in respect of Mr B and the Provision of Mental Health Services, following a Homicide committed in April 2006
Action Plan in response to HIW report 'Ms B'

Report of a Review in respect of Mr C and the provision of Mental Health Services, following a Homicide committed in October 2006
Response to a Report by HIW: A Review in Respect of Mr C and the Provision of Mental Health Services

Report of a Review in Respect of Mr D and the Provision of Mental Health Services, following the Homicide of Father Paul Committed in March 2007 and the Ambulance Response and Care provided to Father Paul's Family and Local Community
Action Plan following the Review in Respect of Mr D and the Provision of Mental Health Services, following the Homicide of Father Paul Committed in March 2007 and the Ambulance Response and Care Provided to the Victim's Family and Community

Report of a review in respect of Mr E and the provision of Mental Health Services, following a Homicide committed in August 2007
Action Plan following the Report of a Review in respect of Mr E and the provision of Mental Health Services, following a Homicide committed in August 2007 - UPDATED MAY 2011

Report of a review in respect of Mr F and the provision of Mental Health Services, following a Homicide committed in December 2008

Report of a review in respect of Mr G and the provision of Mental Health Services, following a Homicide committed in May 2009
Hywel Dda Health Board Action Plan following the Report of a review in respect of Mr G and the provision of Mental Health Services, following a Homicide committed in May 2009 - UPDATED MAY 2011
Pembrokeshire County Action Plan following the Report of a review in respect of Mr G and the provision of Mental Health Services, following a Homicide committed in May 2009 - UPDATED MAY 2011

Report of a review in respect of Mr H and the provision of Mental Health Services, following a Homicide committed in March 2009
Action Plan following the Report of a Review in respect of Mr H and the provision of Mental Health Services, following a Homicide committed in March 2009

Report of a review in respect of Mr I and the provision of Mental Health Services, following a Homicide committed in June 2009
Collated Action Plan in response to the recommendations made in the Report of a Review in respect of Mr H and the provision of Mental Health Services, following a Homicide committed in March 2009

Investigations into Deaths in Prison

From April 2006 HIW took responsibility for the clinical review element of all deaths in Welsh prisons. This role is undertaken on behalf of the Prison Services Ombudsman.

Memorandum of Understanding between HM Inspectorate of Prisons and Healthcare Inspectorate Wales

Investigations into Deaths in Custody

A Memorandum of Understanding is being developed with the Independent Police Complaints Commission (IPCC), which will set out the approach and process for undertaking joint reviews of deaths that have occurred in police custody.

Over the last 12-18 months, there have been a significant number of deaths in police custody where the individual has been abusing drugs and / or alcohol or suffering from a mental health problem. In addition, a number of the deaths have occurred between transfer from police custody to the NHS, or on NHS premises shortly after being released from police custody.

HIW shares the IPCC's view that there are many lessons to be learnt that would hopefully reduce the number of deaths in the future and that the best way to approach this work is by undertaking joint reviews so that interface issues can be better considered.

Memorandum of Understanding between Healthcare Inspectorate Wales and Independent Police Complaints Commission

Prisons and Probation Ombudsman Fatal Incident Reports