Recommendation · source text
Research should be undertaken to review the quality of independent investigations carried out by Strategic Health Authorities.
Source · IAPDC
Workstream paper on Article 2-compliant investigations
Published: 11 May 2011
Sector: Cross-cutting
Type: Guidance
Recommendations: 8
No formal response recorded
Index summary
Early workstream paper examining whether investigations into deaths in custody and detention meet the Article 2 ECHR standard of independence and effectiveness. Contains 8 recommendations on investigation quality, oversight and research.
Original evidence
Recommendations
Recommendation · source text
National Patient Safety Agency (NPSA) good practice guidance on the ‘Independent Investigation of Serious Patient Safety Incidents in Mental Health’ should be re-written when the future governance of NPSA’s functions has been decided to address the shortcomings addressed by the Panel and to ensure consistent application by all Trusts.
Recommendation · source text
Those responsible in the new NHS Commissioning Board should produce adequate guidance to clarify when independent investigations into deaths of detained patients should be triggered; to ensure the person commissioned to conduct the investigation is independent of the provider; and to ensure that all the Article 2 requirements are met.
Recommendation · source text
The Care Quality Commission should devise a specific, discrete role in relation to reviewing deaths of detained patients and consider whether it can undertake and/or commission investigations. It should report back to the Ministerial Board on progress.
Recommendation · source text
The PPO should follow up the analysis conducted in 2009 of clinical reviews, in conjunction with the IAP, to examine the effect of shared governance on quality; timeliness and independence of clinical reviews, six months after implementation, and regularly thereafter. They should share findings of these analyses with the IAP to review progress.
Recommendation · source text
The PPO should be placed on a statutory footing to ensure independence from the Ministry of Justice.
Recommendation · source text
All deaths in Secure Children’s Homes should be investigated by the PPO.
Recommendation · source text
The model for providing standard-setting, guidance and oversight for Coroners should focus on deaths in custody to consider, monitor and ensure improvement in relation to the following: Delays Disclosure/access to documents Family participation Public funding for family legal representation Resources for Coroners
Report details
- Published
- 11 May 2011
- Sector
- Cross-cutting
- Type
- Guidance
Status breakdown
| Open | 8 |
Addressees
| National Patient Safety Agency | 1 |
| NHS Commissioning Board | 1 |
| Care Quality Commission | 1 |
| Prisons and Probation Ombudsman | 2 |
| Ministry of Justice | 2 |