To ask the Secretary of State for Health
(1) what alternatives are being considered to HSG(94)27 for providing auspices for inquiries into deaths in the mental health services; and when they will be introduced;
(2) what assessment has been made of the adequacy of HSG(94)27 in providing the auspices for inquiries into deaths in the mental health services.
Circular health service guidance (94)27 has been an effective mechanism since 1994 for ensuring that thorough investigations are conducted into serious adverse incidents occurring in specialist mental health services. However, in the light of the Chief Medical Officer's report 'An Organisation with a Memory' and the implementation document 'Building a Safer NHS for Patients' published in April 2001, we are establishing a system for reporting, analysing and learning lessons from adverse incidents throughout the national health service. It is important that mental health services should be included in these arrangements.
The new system is currently being piloted and will be rolled out across the NHS from January 2002.
Guidance on the introduction of new arrangements will be issued early next year. In future, all serious service failures or dysfunction will be subject to a full local review to establish what went wrong, to learn lessons and to take appropriate action. In addition, the Department's investigations and inquiries unit will be informed and, in conjunction with the Commission for Health Improvement, will decide whether any further investigation is warranted.