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Homicide Reviews

If a person known to mental health services commits a homicide against another person we may be commissioned by Welsh Government to undertake an independent external review.

Welsh Ministers may commission us to undertake an independent external review when an adult, known to mental health services in the previous 12 months, commits the homicide of another adult. This is to ensure that any lessons that might be learnt are identified and acted upon.

The purpose of the review is 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 findings from our reviews are published to the Special Reviews and Investigation report section of our website.