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Conducting a homicide investigation for NHS England


NHS England commissioned Niche to conduct an independent investigation into the care and treatment of XX and to review the events that led up to an incident which led to the deaths of two elderly members of the public.

We were asked to determine on whether the events could have been predicted or prevented, to review the post internal investigation report and to monitor and evaluate the Trust’s progress in the implementation of the action plan that was based on the findings of the internal report.

Case Summary

XX was diagnosed with a panic disorder. In the months leading up to the incident XX had sporadic contact with community mental health services. XX also had a significant polysubstance misuse history. Since childhood XX had a chronic physical health disease which was progressively and significantly affecting both his mobility and ability to manage his own personal care.

Our Approach

This case met the criteria for the commissioning of an independent homicide investigation as set out in the NHS England’s Serious Incident Framework (2015). Our report was written with reference to the National Patient Safety Agency (NPSA) Root Cause Analysis Guidance.

As part of our investigation we undertook:

  • An extensive review of all primary and secondary mental health services clinical notes
  • Interviewed the various primary and secondary clinicians who had been involved in the treatment of XX
  • Interviewed the Trust’s senior managers to evaluate the implementation of the internal action plan.
  • Both the families and friends of xx and the victims were invited to contribute to our investigation and were provided with feedback from our report.

Our investigation findings

During the course of our investigation we identified the following significant issues that were either unknown to either primary and secondary mental health services or identified within the Trust’s internal report:

  • XX was registered with two primary care services but community services had been aware that patients in their area, who are on methadone programmes, can register with more one primary health care service. The author of the Trust’s internal investigation also failed to highlight this issue. We obtained ample evidence that indicated that XX was routinely misusing his prescribed medication;
  • There was little evidence of liaison between both primary care and mental health services and there was also no attempt to communicate with the probation services in order to obtain an accurate account of XX’s forensic history;
  • XX’s inadequate housing and homeless status was not identified or given adequate consideration within successive assessments or identified as an issue by author of the Trust’s internal investigation;
  • Prison medical services do not share medical information with primary health care services;
  • All involved agencies failed to identify or adequately consider either XX’s known risk factors or take reasonable steps to obtain further information that could have informed their assessments and clinical judgments; and
  • Based on the evidence that we obtained during the course of this investigation, it was clear that XX had very complex needs which required an integrated multi-agency approach to risk assessments, information sharing and support planning. This clearly did not occur and all services were operating in isolation. XX support needs and risk assessments were based on information that was reported by him and it is now clearly evident that he was a consistently unreliable self-historian.

Predictability and preventability

We concluded that even based on the partial and at times inaccurate information it was evident that XX had extremely high risk factors and few protective factors and that there was a significant probability that he would reoffend and that this was likely to have involved violence towards others. However even with improved interagency liaison and assessments given XX’s historical risks as well as his current chaotic lifestyle it was not evident to us if these changes would have prevented him from reoffending. Therefore, we concluded that the incident was probably not preventable.

Publishing of our report

Our report made a number of local and national recommendations. The Trust is currently implementing an action plan to address our recommendations identified. We are also currently providing on-going support to the Trust in order to improve the quality of their internal investigation processes.

NHS England presented our report at a press conference; following this launch our findings and recommendations received both local and national media attention

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